Creating health system strategy when 'policy is out of our control' — 5 questions on ACA repeal with Intermountain CEO Dr. A. Marc Harrison

As Republican lawmakers in Washington mull over how to replace the ACA, health system leaders must continue to create and execute strategies that will enable them to thrive in the short and long term. But with the fate of healthcare reform still up in the air, this task requires as much patience as it does commitment to organizational values.

A. Marc Harrison, MD, who joined Salt Lake City-based Intermountain Healthcare as president and CEO in October, told Becker's his biggest concern related to congressional Republicans' plans to repeal and replace the ACA is what could happen to the estimated 20 million low-income Americans who gained coverage under the law.

As lawmakers discuss how to tear down aspects of the ACA they don't like — such as the individual mandate — while preserving aspects they do like — such as guaranteed coverage for people with pre-existing conditions — this same worry has prompted a shift in the rhetoric among many Republicans to ACA "repair" instead of "repeal and replace." However, some Republicans, including President Donald Trump and Vice President Mike Pence, said they are steadfast in their commitment to completely take down the ACA and replace it with something better.

Here, Dr. Harrison responded to Becker's five questions on the implications of ACA repeal, what he hopes to see changed and how the future of the law could affect Intermountain down the road.

Q: Congressional Republicans have undertaken the difficult and complex task of designing a replacement plan for the ACA. What is your biggest concern in this regard?

Dr. Harrison: My biggest concern is less about keeping the exact same structure of the ACA than it is about making sure people don't get ejected into a no-coverage environment. My worry is that lawmakers will prematurely jettison the ACA without an adequate replacement.

We need a simultaneous repeal and replacement of the ACA. It was just a few weeks ago that I read about a Harvard study that found roughly 43,000 annual deaths could be attributable to ACA repeal if they lose coverage abruptly. We have to remember that healthcare is about the patients — we must do everything we can to make sure patients are not being left behind.

Q: What was your initial reaction when President Trump signed the executive order aimed at immediately lessening the economic burden of the ACA?

AMH: While I'm not a lawyer or a legislator — I read the news of the order, not the actual language of it — my awareness is that we need to keep focusing on our fundamentals. Many of these policy decisions are out of our control, so we must respond in a patient-centered way regardless of what's going on in Washington. The government hasn't spurred Intermountain to take a big left or right turn from our strategy. We're lucky our organization is already well oriented to population health management.

However, I'm not cavalier. I've certainly had a couple of nights where I've stayed up thinking about this. But I think the wisest course for us is to stick to focusing on value and being extraordinarily thoughtful about how we deploy resources.

Q: What do you hope to see preserved in an ACA replacement plan, and what do you hope to see changed?

AMH: There are a few things that I think could work pretty well. For one, the reinstatement of high-risk pools. They existed in more than 30 states before the ACA in both traditionally Republican and Democratic states. These pools are shown to be pretty effective at managing risk for people with pre-existing conditions and chronic disease.

It would also be great if we could allow insurance companies to match the cost of premiums to people's actual expenses, using demographics such as age and other factors. That's how actuarial projections really work.

I also think there should be penalties for people who drop their insurance. It's hard to maintain the principles of insurance if people drop out and buy in whenever they want.

Q: Are you taking any measures to prepare your health system for an ACA repeal now?

AMH: It would be irresponsible to not try to understand the impacts to the organization. We've done some mathematical modeling to determine if we lose X percent of the exchanges, what does that do to revenue and other metrics? But overall we're continuing to focus on getting rid of variation, improving quality, lowering costs and creating novel approaches for contracting. We are trying to think in terms of access and affordability. Whether we're in fee-for-service or value-based reimbursement systems, the value equation always works.

Q: As you look ahead to the future of healthcare in the U.S. and at Intermountain in particular, what's your general outlook?

AMH: I'm not all doom and gloom. If a thoughtful repeal and replacement occurs with mechanisms that are patient centric, we could actually be OK. We could succeed in taking care of these high-risk and complex chronic disease patients. My ask and my hope would be that these decisions were made with the best interest in mind of the people who trusted the government when they entered the exchanges. If their options for insurance are eliminated, many people could be caught in a really unfortunate position.

Above all else, we need to maintain our commitment to provide better value for patients. Given the right tools, we can meet the goals of coverage and care access, and providing care at reasonable costs.

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