Will value-based payment initiatives continue under Trump?

President-elect Donald Trump's promise to dismantle the Affordable Care Act is unlikely to also undo widespread efforts to nudge the U.S. healthcare system toward value-based payment, including experiments devised by the ACA-funded Center for Medicare & Medicaid Innovation.

“The concept of value in healthcare has been around a long time,” said Helen Darling, interim president and CEO of the Washington, D.C.-based National Quality Forum. Fundamental ideas like the importance of transparency and data to patients, providers and competition existed well before the Affordable Care Act, and they are as Republican as they are Democratic, she said. “Some of those things are more Republican than Democrat, frankly,” she added.

How Trump and the Cabinet he selects will interpret these longstanding principles is another question, and healthcare policy and payment reform experts caution that the answer won't become clear until well into 2017 or beyond.

Eliminating the ACA in its entirety, as Trump promised during the campaign, would mean axing the CMS Innovation Center, which was established under the law and given $10 billion in funding through fiscal 2019.

Its purpose is to test “innovative payment and service delivery models to reduce program expenditures … while preserving or enhancing the quality of care.” As such, the Innovation Center has fostered accountable care organizations, implemented voluntary and mandatory bundled-payment programs and rolled out a slew of other initiatives. HHS says more than 4.7 million people enrolled in Medicare, Medicaid and CHIP have gotten care through the models.

The Innovation Center is one of the leading entities looking at the viability of healthcare programs and their costs, said Mike Thompson, the president and CEO of the National Alliance of Healthcare Purchaser Coalitions. “My sense is that the CMS Innovation Center is aligned with both sides of the aisle,” he said.

Some Republicans have criticized the Innovation Center's recent moves toward mandatory demonstrations, particularly its effort to change how Medicare Part B pays for drugs administered in doctors' offices and hospital outpatient departments.

But Democrats and Republicans alike have indeed recognized the need to lower costs and improve the quality of healthcare delivery. The Bipartisan Policy Center, for instance, published a report last year by former Senate Majority Leader Tom Daschle, a Democrat, and former House Speaker Newt Gingrich, a Republican whose name has been floated for Trump's Cabinet.

The report recommended that states “advance new and innovative approaches to health insurance coverage” by taking advantage of different components of the Affordable Care Act, including models tested by the CMS Innovation Center. The report broadly acknowledged the need for expanding coverage and improving the value of healthcare by lowering costs and improving quality.

Citing this type of bipartisan support, Blair Childs, senior vice president of public affairs at healthcare improvement company Premier, predicted that “calmer heads” would prevail and preserve the Innovation Center. Its budget might be reduced, he said, but both sides of the aisle recognize its work as necessary.

“The reality is, Medicare needs to be reformed,” Childs said. “So you need some mechanism to test and scale new models in fee-for-service Medicare. And so I think CMMI will in the end survive.”

Efforts to move away from fee-for-service to value-based care are also enshrined in places besides the Affordable Care Act. “This is a movement that's happening independent of the ACA, or parallel to it,” said David Jones, an assistant professor of health law, policy and management at Boston University's School of Public Health.

“My sense is (Republicans) are really gunning for the Medicaid expansion, the health insurance exchanges and the premium tax credit,” Jones said. “It's very unclear when they say they're going to repeal Obamacare whether they're even thinking about things like CMMI or to shift away from things like fee-for-service.”

The bipartisan Medicare Access and CHIP Reauthorization Act allows physicians who participate in advanced alternative payment models to bypass the reporting requirements and potential penalties under a new incentive framework. Those models include several created by the Innovation Center.

“MACRA creates the impetus for moving away from fee-for-service,” said François de Brantes, executive director of the Health Care Incentives Improvement Institute. If the ACA was the only legislation to foster alternative payment models, “that'd be cause for concern,” de Brantes said. “But it isn't.”