Three of the Most Overlooked Health Care Reform Stories of 2013

While media coverage of the Affordable Care Act reached a new high in 2013, many important ACA-related stories were shortchanged in favor of minute-by-minute stories about the launch of federal and state health insurance exchanges and the delay of various provisions of the law.

In December, Road to Reform explored three of the most overhyped ACA stories of 2013. This companion column dives into the opposite: three health care news stories that were overlooked in 2013.

Accountable Care Organizations

Although accountable care organizations have been described as the linchpin of the ACA, there was a dearth of news coverage on the programs in 2013.

ACOs are networks of doctors, hospitals and other providers that coordinate care and share responsibility and financial risk. The goal of coordinated care is to ensure that patients receive high-quality treatment while avoiding unnecessary duplication of services and preventing medical errors. Under the model, provider reimbursements are tied to quality metrics and reductions in the total cost of care.

The bulk of ACO coverage in 2013 came in July, when multiple organizations announced that they were dropping out of CMS' "Pioneer" ACO demonstration project.

Under the Pioneer program, which launched in January 2012, participating providers contracted with CMS to meet quality targets and assume new risk when caring for a set population of Medicare beneficiaries. All 32 ACOs in the program improved the quality of patient care in the first year, but only about one-third lowered costs enough to generate shared savings, according to data released by CMS.

This summer, nine of the 32 ACOs said they will not continue participating in the Pioneer program. In a press statement, CMS noted that two of the ACOs opting out of the program "shared losses totaling approximately $4.0 million." At the same time, 13 of the 32 participants generated a gross shared savings total of $87.6 million in 2012, according to CMS.

Beyond that story and another noting the delay of a nationwide pilot program for a Medicaid accountable care organization for pediatric care, the media seemed to have largely forgotten ACOs last year.
News outlets at least could have kept up with the rising number of ACOs. This summer, Wendy Everett -- president of NEHI, previously known as the New England Health Institute -- told California Healthline that there were about 250 ACOs in the country at that time, while another 500 groups had submitted applications to form such organizations. In a Kaiser Health News FAQ published in August, Jenny Gold noted that more than 428 hospitals had joined an ACO and that an estimated 14% of U.S. residents were being served by an ACO, whether they knew it or not.

In California, a report by Catteneo and Stroud -- which received little attention from the media -- found that as of July, about 100 ACOs covered 644,900 Californians in 32 counties statewide. More local coverage from December reported that four California medical groups participating in Anthem Blue Cross' ACO experienced clinical quality gains since joining the program.

There also was a slew of news reports on hospitals laying off staff and blaming the ACA, which ignored those hospitals that actually have increased staff because of the success of patient-centered medical homes and ACOs and the added revenue such programs have drawn.

MLR Savings

Despite plenty of coverage of the negative aspects of the ACA, like the technology glitches on HealthCare.gov, there wasn't much ado about the more positive results of the law -- namely, savings derived from the new medical-loss ratio provision.

Under the provision, private insurers must spend at least 80% in the individual market, or 85% in the group market, of premium dollars on direct medical costs. Insurers that do not comply with the ratio must issue rebates to consumers.

In June, HHS Secretary Kathleen Sebelius announced that the MLR provision helped U.S. residents save about $3.9 billion in 2012 through a combination of lower health insurance premiums and rebates. In addition, HHS estimated that consumers through the rest of 2013 would receive an average rebate of about $100 per family.

CMS Deputy Administrator Gary Cohen said insurers paid fewer rebates in 2012 than in 2011 because they are more strictly adhering to the law and charging lower premiums up front. Cohen said, "As [insurers have] adjusted their prices to the new rule, as they've become more efficient and more cost effective, two things happen: the number of rebates goes down and the corresponding amount of premium that people have to pay for the value they are getting for insurance comes down as well."

Sebelius touted the savings as an immediate benefit of the ACA and evidence that the law will make insurance coverage more affordable.

Disease Prevention and Public Health

Amid all of the news coverage this year of rising health costs, not much was said about disease prevention, which is considered by many to be the most important ingredient in keeping individuals out of hospitals. The Robert Wood Johnson Foundation has issued a series of reports finding that prevention saves lives, improves quality of life and may reduce overall health care costs over the long term.

One RWJF report released in December that barely received news coverage -- "Return on Investments in Public Health" -- examined steps taken by San Diego County to boost public health and lower health care costs in the region.

According to the report, the county has begun a major effort to reduce and prevent obesity, which can contribute to cardiovascular disease, cancer, Type 2 diabetes and respiratory conditions. Last year, the county began a 10-year, $16 million project, known as "Healthy Works," to develop policies that encourage exercise and better eating. The project focuses on making long-term environmental and policy changes to encourage physical activity and healthy eating. For example, county officials are working with regional planners to ensure that transportation plans include bike trails, walking paths and other ways to promote physical activity.

California State Controller John Chiang said, "The economic cost to California of adults who are obese, overweight and physically inactive is equivalent to more than a third of the state's total budget," adding, "Think of the programs we could protect, the children we could educate and the families we could help if we could recapture those dollars by investing in prevention."

Outside of the RWJF studies, one of the few instances of disease prevention coverage appeared in the Dunkirk Observer in December. The article examined a comprehensive assessment of health conditions and a public health improvement plan released by the Chautauqua County Department of Health and Human Services in New York.

The assessment identified several public health issues, including obesity and chronic disease. To address such issues, the plan seeks to reduce obesity in children and adults over the next three years by creating community environments that promote and support healthy food and beverage choices along with physical activity. The plan also hopes to boost mental health by fostering collaboration among professionals working in fields of mental health promotion and chronic disease prevention to integrate screening and treatment.

The Big Picture

Why does it matter that these stories were under-covered in 2013? Because it gives the news landscape a distinctly anti-ACA slant -- which some experts would say is unfair.

While a handful of publications covered the MLR savings announcement in June, the news was quickly forgotten as analysts counted the days and problems until open enrollment began in the fall. Once the exchanges opened, much of the news continued to focus on problems in the marketplaces, as well as other ACA topics that skewed negative, like the debate over the individual mandate delay. While the MLR savings story did not have continual updates like the aforementioned topics, it seemed that evidence of the law having a positive effect on the health insurance industry was lost in talking points about whether ACA was a disaster or just a gargantuan disappointment.

In addition, the lack of coverage sets a precedent for overlooking stories that will continue to be important in coming years, such as ACOs and public health strategies.

Along with the health insurance exchanges and the Medicaid expansion, ACOs are the third part of a triumvirate of crucial ACA initiatives. Some observers might even argue that the organizations are the most important part, as they seek ground-level changes in how doctors treat patients and are rewarded for their work rather than simply overhauling how individuals obtain coverage.

It's also unfortunate that stories about disease prevention and public health strategies did not get more traction in 2013. While news reports of something like the technical glitches on the federal exchange website are informative, they do little to help local and state officials who cannot take steps to help the situation. Conversely, coverage of Chautauqua County uniting efforts to reduce obesity and boost mental health under a single initiative might give such officials a new idea to improve health in their own regions. These are the stories that decisionmakers should be reading.

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