Throughout my 37 years in healthcare, I have been called upon to participate in and lead efforts to introduce complex change into organizations such as medical schools, hospital systems, large medical practices and patient advocacy groups.
Years ago, I started using Dr. Mary Lippitt’s concept of complex change to understand why some efforts succeeded and others failed.
Lippitt taught that one needed vision, incentives, skills, resources and an action plan for such programs to succeed. When any one of the above five components are missing, confusion, resistance, anxiety, frustration and false starts occur.
During recent visits to Illinois and New Jersey to meet with physician groups, I encountered people who exhibited all of the above-described reactions to the dysfunctional attempt to introduce complex change into the American healthcare delivery system.
In discussions about MACRA and the fate of the Affordable Care Act, many expressed confusion about the vision of the Trump administration. Trump supported the Graham-Cassidy bill that aimed to overturn the ACA by embracing block grants to encouraging states to opt out of the law’s insurance requirements. Trump also reportedly contacted Centers for Medicare & Medicaid Services Administrator Seema Verma to block Iowa’s application to opt out of the ACA and implement its own conservative model.
It is hard to see how these seemingly contradictory decisions by the president support a clear vision for the future. The lack of a GOP consensus on what to replace the ACA with contributes to the widespread confusion among healthcare providers. Visions that are successful are easy to understand, provide a reason for the change and are widely shared by those most affected.
When incentives are not clear or misaligned, proponents of change often encounter resistance. For example, health insurers have raised their premiums for 2018 because they are uncertain about the rules of the game—especially given the unclear future of cost-sharing reduction payments.
And on Thursday, Trump signed executive order that aims to allow people to form association health plans in order to buy insurance across state lines—a move that could leave ACA exchange insurers stuck with sicker and older patients. These actions by the administration are not providing the incentives insurers say they need to stay in the individual markets or lower premiums.
While insurer financial performance did worsen in 2014 and 2015 and premiums did rise, a recent analysis of individual market medical loss ratio and margins for midyear 2017 concluded that the markets are stabilizing and insurers are regaining profitability.
However, this trend may not continue because the Trump administration has cut the advertising budget for 2018 ACA enrollment by 90% and the navigator program by about 40%. The Trump administration has also decided to shut down Healthcare.gov for 12 hours on Sundays during open enrollment and to cut the number of days citizens can enroll in half.
In addition, my recent trips did little to reassure me that physician groups and hospitals have the skills necessary to succeed in participating in the MACRA/MIPS payment reform that is now the law of the land. CMS appears to be encouraging physicians and hospitals to assume more risk so that they qualify for the bonuses associated with Alternative Payment Models and avoid the transparent MIPS scores for individual physicians. However, there is a gap between the necessary skills to manage downside risk and the current level of physician understanding and competence.
Even if vision, incentives, skills and resources are clear, well-defined change initiatives often fail if they do not have an action plan so that everyone involved knows what and why they need to change. My encounters with physicians and hospital leaders reveal that the effort to change the American healthcare delivery system is lacking all five essential components of a successful program. All of us can expect the next year to be confusing, anxiety provoking, frustrating and unsuccessful.
Kent Bottles, M.D., is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.