The Future of Clinical Pathways: The Potential Impact of the Presidential Election

Although the topic of health care will continue to be a political one, the continued growth of public health care spending suggests that the government will need to continue its shift toward improving the value of health care delivery. The development and use of clinical pathways are consistent with this shift and will likely continue to be utilized. Still, each presidential candidate has differing views on health care reform, specifically with regard to the roles of the government and the free market. This raises the question of how the future of clinical pathways will be affected by the results of the presidential election in November.
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While many have speculated about how the outcome of the US presidential election in November will impact the future of health care, the current shift from a fee-for-service model to value-based reimbursement is likely to continue regardless of the political outcome, owing to the continued increase in public health care spending each year (Figure 1).1 While this shift will continue to emphasize delivery of the Triple Aim (individual care, cost effectiveness, and population health) and evidence-based care—both of which necessitate the use of clinical pathways—the structure of pathways and their use will be affected in different ways depending on whether we see Hillary Clinton or Donald Trump win the presidency, as both presidential candidates have announced very different visions for the future of health care in the United States.

healthcare spending

THE CANDIDATES' HEALTH CARE PROPOSALS

The focus of Mrs Clinton’s proposals with regard to health care has been affordability.2 Supporting the expansion of the Affordable Care Act (ACA), she has promised the quick advancement of legislation to provide 3-year full federal payment for states that have not expanded Medicaid and has proposed solutions to issues that have arisen from the ACA, including fixing the “family glitch” permitting subsidies for family coverage for individuals; modifying the “Cadillac Tax” to reduce the penalty on high-cost health plans; and fixing the reinsurance mechanism in order to stabilize the insurance exchanges. Mrs Clinton has also promoted other affordability-oriented reforms, such as expanding the regulation of drug prices, creating a $5000 tax-deductible savings account to cover co-pays and deductibles, encouraging standardized health plans and regulation of rates, supporting Medicare buy-in for people aged ≥55 years as a “public plan” option, and continuing the movement toward bundled payment and global payment models.

In summary, a Clinton administration would focus on decreasing patient out-of-pocket costs by increasing access to insurance, exerting downward pressure on pricing through regulations and health system involvement, and placing a greater burden of responsibility on the health system through provider utilization controls for clinical and financial risk and increased use of pay-for-performance programs.

In contrast, Mr Trump’s approach focuses on controlling costs.3 He has proposed repealing the ACA and eliminating the individual mandate; modifying existing law that prohibits the sale of health insurance across state lines; and block-granting Medicaid to the states, working with states to ensure that those who want health care coverage can have it. Individuals would be allowed to fully deduct health insurance premium payments from their tax returns as well as increase their use of Health Savings Accounts (HSAs). He would also require price transparency from all health care providers; remove barriers to entry into free markets for drug providers that offer safe, reliable, and cheaper products both via reimportation and increased access to generics and biosimilars; eliminate fraud and waste; eliminate health care for illegal immigrants; increase employment to reduce the number of individuals needing access to programs like Medicaid and Children’s Health Insurance Program; and reform mental health programs and institutions.

In summary, a Trump administration would focus on the traditional health care triangle of access (broadening health care access); cost (making health care more affordable, through increasing competition and means testing for access to additional funding sources); and quality (improving the quality of the care available to all Americans).

IMPACT ON CLINICAL PATHWAYS

To compare these differing views as they specifically apply to clinical pathways, we consider four key questions:

Who will dictate clinical pathways?

Mrs Clinton has long been a supporter of government funding for comparative effectiveness research and organizations like the Agency for Healthcare Research and Quality (AHRQ). Its mission is to produce evidence to make health care safer; higher quality; and more accessible, equitable, and affordable, and to work within the US Department of Health and Human Services and with other partners to make sure that the evidence is understood and used. Considering this past support for the mission and philosophy of government involvement in health care reform, Mrs Clinton may be supportive of government-led efforts to implement and enforce standards for clinical pathway development.

In contrast with Mrs Clinton’s support for a role of government in the provision of health care, Mr Trump’s support for following free market principles means that private groups such as academic centers and medical associations will likely be left to lead the development of these resources.

What specific treatments will be included in clinical pathways, and how will these treatments be reimbursed? 

Given Mrs Clinton’s focus on equal access to health care, she is unlikely to be supportive of clinical pathways that narrow treatment options for patients. In addition, under Mrs Clinton’s proposals, the government would play a much stronger role in the direct negotiation of drug prices, preventing the need for large disparities in drug costs to play a role in pathway decisions. With regards to reimbursement, Mrs Clinton has proposed a cap for monthly and annual out-of-pocket costs for prescription drugs for patients with chronic or serious health conditions.

Mr Trump’s free market approach, including support for increased competition and the reimportation of overseas drugs, as well as his support for greater price transparency may also lead to reductions in the cost of drugs. Also of interest is Mr Trump’s focus on individual responsibility for health care insurance coverage, signaling that clinical pathways would need to include flexibility to account for differences between patients’ treatment coverage. Although Mr Trump has not advanced any proposals regarding out-of-pocket costs to patients for prescription drugs, under his plan, individual HSAs could be used to cover patients’ prescription drug costs.

Where will clinical pathways be utilized?

Mrs Clinton’s focus on value-based reforms to Medicare and Medicaid, with payments being linked to outcomes, suggests that she may be supportive of implementing requirements for clinical pathways as part of these programs. As mentioned previously, she may also be supportive of the Centers for Medicare & Medicaid Services implementing recommended standards for clinical pathways as well as defining their outcomes measures. There may be a struggle to determine which will come first—the outcome measures or the pathway recommendations.

Under Mr Trump, with a favor toward private sector over government institutions, clinical pathways will likely continue to be used independently by payers and health systems as a means to improve their performance on various quality and value measures.

How and to what degree will clinical pathways be used? 

Under a Clinton administration, pathways, which are tied directly to accountable outcomes, will leave providers with very real reasons to be adherent to them. In addition, the shift of providers to health systems, and the extended reach of their electronic medical records within these health systems, will further force providers and health systems to be adherent to pathways.

Mr Trump’s team has already written that attributing poor adherence to ill-informed patients leads to ineffective, and potentially harmful, policy efforts to improve adherence. With this type of thinking, Mr Trump’s support of strict adherence requirements for pathways may be somewhat limited.

THE FUTURE OF PATHWAYS

In the end, whatever the outcome of the election in November, the use and specificity of clinical pathways will no doubt continue to grow. This will be driven by a focus on the delivery of high-value care, which relies on the implementation of clinical pathways through providers working in health systems utilizing an increasingly sophisticated electronic medical record environment. Instead, the election results will impact the extent to which clinical pathways are used and whether the public or private sectors will be the main drivers of pathway development and implementation. 

References

1.    Centers for Medicare & Medicaid Services. National Health Expenditure Data. cms.gov website. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html. Updated December 3, 2015. Accessed September 21, 2016.

2.    Hillary Clinton 2016. Health care: Universal, quality, affordable health care for everyone in America. Hillary Clinton website. https://www.hillaryclinton.com/issues/health-care/. Accessed September 17, 2016.

3.    Donald J Trump for President. Healthcare reform to make America great again. Donald J Trump for President website. https://www.donaldjtrump.com. Accessed September 17, 2016