Here's what CEOs think of candidates' healthcare ideas

The nation's top healthcare leaders overwhelmingly back the Affordable Care Act and support its goal of pushing providers away from fee-for-service medicine and toward delivering value-based care, according to Modern Healthcare's second-quarter CEO Power Panel poll.

While the Republican Party and its presumptive nominee, businessman Donald Trump, continue to stand by their “repeal and replace” slogan, the sector's CEOs overwhelmingly reject that idea, in large part because they are unimpressed with the GOP's attempts to articulate what it would replace it with.

But at the same time, only a small group supports moving to a single-payer system, which has been a central theme of Democratic presidential candidate Bernie Sanders' surprisingly resilient campaign, which he has vowed to continue through the party's convention this summer in Philadelphia.

The overwhelming message from the survey, which covered a range of issues raised on the campaign trail this year, was that the next president and Congress should stay the course set by President Barack Obama and the ACA. But healthcare leaders are also looking for the nation's political leadership to reject complacency and look for ways to improve what they see as a far-from- perfect piece of legislation.

“I think the Affordable Care Act needs to stay, and we need to keep improving it,” said Dr. Gary Kaplan, CEO of the not-for-profit Virginia Mason Health System in Seattle. “I think that we can put together great minds and make some further improvements and hopefully take it out of being a political football.”

The CEO Power Panel includes 110 top leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups. The second-quarter survey on policy options that the next president and Congress might address attracted 86 respondents, a 78% response rate.

More than two-thirds of the CEOs declared outright that they opposed repealing and replacing the ACA, and nearly all the rest said it depends on how that might be done. Only 2.3% of respondents endorsed that approach.

While only 34.9% of respondents said they wanted to expand the ACA to achieve universal coverage, which has been central to Democratic presidential candidate Hillary Clinton's health policy proposals, half of all respondents said they were open to the idea but wanted to see more details.

When asked about creating a single-payer system such as an expanded and enhanced Medicare program in place of private insurance, less than 10% supported the idea and 61.6% flatly rejected it. The rest said it depended on the details.

Tom Priselac, president and CEO of Cedars-Sinai Health System in Los Angeles, said it's impossible to judge models on those ideas without more specific information to help assess their impact on healthcare access, quality and affordability. And American patients might be quite slow to warm to the concept.

“A single-payer system, once defined sufficiently so that the pros and cons can be understood, will only be politically feasible once it is sufficiently socially acceptable,” Priselac said. “Americans still place a very high value on choice.”

In a finding that should sit well with CMS officials, the survey revealed overwhelming support for a continued push for value-based payment, accountable care organizations and the use of quality measures included in the ACA. Nearly 84% of CEOs said they did not want efforts to transform the delivery system to go away.

“I hope (it stays) because I think it aligns our financial interests with our patients' interests in a better way than the current model, for certain,” said Dr. Penny Wheeler, president and CEO of Allina Health in Minneapolis. “So I do see it staying just from a practical standpoint, and I do hope it stays and expands from a mission perspective."

With the recent release of nearly 1,000 pages of rules regarding the Medicare Access and CHIP Reauthorization Act and how it will reimburse doctors and hospitals based on quality measures, executives said that while they are anxious for its rollout and further details, they have no question that the general direction is the correct one.

“You can't do something so complex when there's so much uncertainty,” said Dr. Michael Pramenko, executive director of Primary Care Partners, a health system in Grand Junction, Colo. “Because you need people on board, and you need good leadership. And you need an understanding that policy requires a really grown-up approach to politics. If you have the politicization of policies as we have it now, you're not going to get where we need to go.”

Wheeler said the current phase of transitioning from fee-for-service to value-based payment models forces providers to straddle two worlds. “So the biggest concern is making sure you have the right infrastructure and physician alignment and everything you need to perform in a new value-based world,” she said. “And the challenge is we're not going to be living in that world solely either.”

On other issues, some of which have been covered in previous Modern Healthcare CEO polls, executives were eager to see expanded efforts to curb the dramatic escalation in prescription drug prices, an issue that has galvanized political action by patient advocates, insurers and politicians. About 7 in 10 CEOs surveyed said they supported “aggressive measures to curb rising prescription drug prices.”

Prescription drug spending rose 12.6% in 2014, and prices for many generic drugs have been rising faster than inflation. A Vermont bill that requires pharmaceutical companies to explain their price increases is expected to be the first of its kind to be enacted. At least five other states have considered such legislation.

Wheeler said prescription drug prices are crowding out other healthcare needs and forcing administrators to make tough decisions. “At a time when our total expenses are rising 4% and our revenue 2%, there's already a delta there which we're adding to,” she said. “And it makes for much more difficult choices about your workforce and how many (employees) you can afford, your benefits and how many you can afford.”

Democratic presidential candidates have called for allowing Medicare to negotiate drug prices, as well as loosening restrictions on drug importation and capping out-of-pocket expenses for medication.

Dr. William Conway, CEO of the Henry Ford Medical Group in Detroit, said he is still considering which approaches might be best, but he knows action needs to be taken. “One would hope that that would be a prominent part of any new administration,” he said, “because it's unjust what is happening to this country.”

Healthcare leaders proved politically agnostic when it came to proposed changes to Medicare and Medicaid, backing Republican approaches for the former and Democratic stances on the latter. A little more than half of respondents said elected leaders should begin addressing the long-term financial needs of Medicare, the nation's program for caring for the elderly and disabled, by raising the eligibility age to 67.

Half of survey respondents said they would like to see expanding means testing within the program. And a plurality backed moving to a universal Medicare Advantage system with premium support for seniors, an overhaul pushed by House Speaker Paul Ryan and other Republicans for many years. While the 28.2% in favor of the idea was greater than the 20% who were opposed, 48.2% wanted more details before they could back such a dramatic change in the program.

Wheeler said circumstances have simply changed too much to keep Medicare as it is and expect it to remain sustainable.

“It was a formula that was set up years ago before we had the longevity of life that we have today and before we had the resources available to us and the treatments making some chronic illnesses, which were death sentences, into long-term chronic illnesses,” she said. “It's absolutely important to raise (the eligibility age) commensurate with the longer length of life we have.”

Those worries about the financial stability of the program led just under half the respondents to reject gradually expanding Medicare to cover everyone over age 55 who doesn't have private insurance, a proposal Clinton championed on the campaign trail this month. Only 21.4% backed the idea and another 28.6% wanted more details.

But regarding Medicaid, which provides health insurance for the poor, few executives were ready to sign on to plans for turning the program into capped block grants to the states, with or without strict federal requirements. Priselac said block grants move away from the program's two long-standing principles—giving states some flexibility while still maintaining national standards for coverage.

“A block grant program is not consistent with important design principles of Medicaid that are as relevant today as they were when the program began,” he said. “The Medicaid program was established with (those) two important design principles in mind and from a political standpoint represented an effort to balance federal and state interests while doing so.”

Some of the ideas put forward by ACA opponents received at least moderate approval in the poll. Nearly 75% said they would like to see expanded use of health savings accounts. But less than half were fans of high-risk pools and about 52% supported allowing health insurance to be sold across state lines.

Kaplan of Virginia Mason said the problem is that those are the only alternatives being tossed around, and they're not enough. “I think the ability for those things to actually have a positive impact and mitigate some of the weaknesses of the Affordable Care Act is really not real,” he said.

In conversations with CEOs who answered the survey, a common theme was utter frustration with politicians intent on creating sound bites instead of sound policy.

Wheeler said the current election and the popularity of Sanders and Trump show that voters are fed up with the political system and the parties that run it.

“I wish that the rhetoric about getting rid of the Affordable Care Act would just cease,” she said. “It's wasted noise that our country doesn't need. Focusing attention on what actual aspects of the Affordable Care Act need to be improved upon would be more of what I'd like people to focus on.”

Pramenko agreed and said the failure of ACA opponents to articulate a real alternative “speaks volumes about the state of our political discourse in this country.”

“You can't just say I'm going to repeal the Affordable Care Act,” he said. “I would call it irresponsible and naive, and it puts politics well above any good policy.”