Ferd MitchellThe various problems that have plagued implementation of the Affordable Care Act (ACA) and the responses to these problems have received widespread coverage in the media. Hospitals and other medical facilities can draw both positive and negative lessons from these occurrences.

As passed by Congress, the ACA was a political document, and there seems to have been relatively little attention given to the need for a carefully crafted implementation plan. Many of the resulting problems may be traced back to this lack of foresight, and it is here that hospitals can learn some important lessons.a

Cheryl MitchellThe first lesson is that a good plan, based on a clear analysis of actual circumstances, can help hospitals get off on the right foot, whereas a bad plan, based on wishful thinking, can place hospitals at a disadvantage from the start.

During the early years of implementation of the ACA, there appears to have been insufficient effort devoted to setting up meaningful lines of communication with all affected individuals and organizations. The consequences underscore the second important lesson for hospitals: For new hospital programs, it is important to open up numerous lines of communications with all affected individuals and organizations and support the exchange of information throughout. Implementation activities that are directed only toward the inner organization can fail to elicit the needed outside engagement.

Last-minute ACA communications efforts have tended to be ad hoc and underfunded. The lesson for hospitals and other medical facilities is to make sure sufficient attention is given to sound advance planning to avoid crisis responses to communications issues. It is critical to assemble and define realistic tasks, costs, and schedules from the start.

The ACA difficulties illustrate the danger of rushing any initiative that will bring major change into effect. Hospital managers should stick to their own assessments regarding the pace of change that is viable, and not allow themselves to be pressured into more rapid action.

ACA implementation seems to have been focused on rushing to meet its ambitious deadlines and on acceptance of delayed decision making. As a result, technical problems now threaten the  implementation, and late fixes are being accepted. By all appearances, the Department of Health and Human Services (HHS) failed to bring together the most experienced persons and organizations in the field and to give them the management structure and support to make sure they could do the job.

Another insight is that, once program implementation is under way, special emphasis should be placed on avoiding last-minute changes in specifications. Think of what happens if an architect is asked to redesign a facility in midstream: frustration, a cost explosion, and chaos.

Most recently, HHS has taken new steps to manage the technology crisis, which can serve as a useful model for hospital managers.

The primary positive lesson—which applies to virtually all program implementation efforts today, given that they all are likely to involve technology—is for hospital managers to recognize that they will often need help to supervise programs with technical components. A high-profile technical leader may be appointed to represent and guide the technical tasks and advise the manager. An outside team of experts may be assembled to analyze the development process and advise the technical leader and hospital manager. A formal process should be put in place for budgeting, scheduling, and supervising all technology-related tasks. 

Experience has shown that managers often cannot adequately integrate all implementation activities without such support. Relying on the technical teams alone usually does not assure accountability. A technical leader and team of outside experts can provide essential information that is needed to allow nontechnical managers to effectively supervise technical tasks.

These moves should be taken at the start of implementation. It is often too late to try to step in and impose order on a project once it has started to unravel. 


a. See also the recent blog posting “The Obamacare Report (#17) / Political Drama — Good or Bad for ACA Implementation Efforts?” for additional discussion by the authors of the impact of the ACA  program failures and their implications.   

Ferd H. Mitchell is an attorney, Mitchell Law Office, Spokane, Wash., and a member of HFMA’s Washington-Alaska Chapter.

Cheryl Mitchell is an attorney, Mitchell Law Office, Spokane, Wash.

Publication Date: Friday, November 08, 2013