Wrapping up the CI Summit with a Health Affairs Chat
The Care Innovations Summit wrapped up with a fireside chat, and moderator Susan Dentzer observed that there hadn’t been much discussion about the Medicaid population throughout the day, even though the summit was co-hosted by the Centers for Medicare and Medicaid Services. Dentzer asked Deputy Administrator Director of CMS Cindy Mann how innovation could play into the care of the Medicaid population.
Mann mentioned three major ways: experimentation (with payment rules and service delivery), peer to peer learning and data. Though she mentioned data last, she emphasized it the most.
“We need to be much more intentional about getting the data that we need to see what’s working, what’s not working,” Mann said.
But even before that, CMS needs to keep track of Medcaid beneficiaries even after they’ve left the system, she said. People can move out of the system quickly, as they might be offered employer-based coverage when they didn’t once have it. And with the Affordable Care Act, people who will be eligible to buy insurance through the health insurance exchanges will start getting their coverage there. Mann said that we’ll need systems that track data across different branches, so we can keep tabs on who’s covered and who isn’t.
“Only when people are having the coverage on a continual basis are we really able to concentrate on quality and improving care,” she said.
Basic science, clinical data, and the personal desires of the patient
Despite spending $150B a year on cancer diagnosis and treatment in the United States, the statistics are bleak: 85% of lung cancer patients die within a year and 15% of new cancer diagnoses are incorrect.
In trying to learn where cancer care might be improved, the #CISummit audience listened closely to the immense wisdom of Amy Berman, who courageously shared learnings from her own personal journey with cancer.
For Amy, what has been difficult yet most meaningful in her own struggle, has not been navigating clinical trials data but has been working with physicians to define and articulate her own goals.
In laying out a roadmap on how to put patients at the center of care, she made the following recommendation: “I would say that I’m very hopeful that people want to do the right thing, but right now the infrastructure is not supportive of the right thing. For example if we go back to the EMR, there is no standard way to capture what that patient’s goal is.”
“There is a growing movement for Physican Orders for Life Sustaining Treatment (POLST) but its not incorporated into EMR. You need to know not just the diagnosis but the course of disease, choices around treatment, and the impact of that choice is on you and your quality of life. Its a partnership between the doctor and patient but ultimately is the patient’s health at stake and the patient has an important role to play here.”
As she boldy concluded: “There are no wrong choices only informed choices”.
How Do You Find and Define Who Needs Care?
After delivering an opening keynote at the Care Innovations Summit, Dr. Atul Gawande returned later to moderate a panel on delivering care to the chronically ill. In a conversation with Gawande, CEO of WellPoint/CareMore Alan Hoops told him that CareMore, a health plan and heal care provider, is able to deliver more tailored care than a senior’s regular primary care provider. Hoops said that primary care doctors are relieved to know that these patients are being cared for in an intensive system.
This prompted Gawande to respond, “You need to be selective about who you put that intensive care with. We have intensive care units in hospitals, and part of making them really valuable is ensuring that it is for the people who need it the most.
Then he asked of the panel: “How do you find and define who’s appropriate?”
CEO of WellPoint/CareMore Alan Hoops:
“For CareMore we define it however we possibly can. I indicated that one of the critical success factors is predictive modeling. And frankly, we throw everything but the kitchen sink at predictive modeling. The best predictive modeling event is the acute care episode for the senior.
Statistically 50% of all seniors who are admitted die or are readmitted within a year. About 20 to 25% of seniors are dead within a year. So this is a big-time predictor for the seniors.”
“But we use everything we use some statistical modeling, we use a program … we come up with home made things. We, for a while, looked at any female 90 years old, living alone. That was a predictive model. So we use any way we possibly can to give us as much runway as possible to determine when that patient is going to hit the point of inflection on that slope and go from being a relatively healthy person to being a very needy and complex person.”
Professor in Gerontology at University of Pennsylvania School of Nursing Mary Naylor:
“Ours is an evidence-based model. Risk screen has been grounded in multiple NIH clinical trials where we’ve tracked for over a year, the experience of people and their outcomes and been able to predict, not predict, but to identify those individuals who are at a point of risk that if we don’t intervene will be back into our costly health care system.
So it is based on both randomized control trials as well as testing the transitional care models against other evidenced-base approaches.”
“It’s a risk screen that has a number of factors so we are focused on Medicare beneficiaries. We are focused on dual eligible populations. We are focused on individuals with multiple complex conditions, individuals who in the past 30 days have some kind of acute service use, individuals who in the past six months have multiple acute service use, individuals who screen as cognitively impaired (which we often don’t screen consistently in our health care system), individuals who screen as depressed. So those are among the risk factors.”
CEO and Medical Director of Health Quality Partners Kenneth Coburn:
“This in the area of hot research right now. And on the slide I showed several risk groups and that’s because when we started the model with Medicare coordinated care demonstration, we had low, medium and high risk groups based on classification using a questionnaire with permission from the Sutter Health Organization, which we found very helpful for teeing up the needs of patients for the model with nurse. Mathematical policy research, the CMS rapid evaluation team have looked at this data lots of different ways and sliced and diced it, and the group that we’re targeting now, based on their analysis, are folks that have either heart failure, coronary artery disease, diabetes, COPD and one or more hospitalization in the preceding year. So I think the estimate, if I have this figure right was somewhere between 14 to 18% of all Medicare beneficiaries would fall in that group.”
Culture, Process and Technology
Members of the primary care innovation panel agreed that the health care system needs to move away for the traditional fee for service model. Their discussion brought up three immediate challenges to doing that: innovations around technology are essential, but they’re not enough; in the end, reforming the system isn’t going to change anything if patients aren’t on board; and it’s hard to get people, especially physicians, to adopt new ways of thinking.
It sounded ambitious, but CEO of Essence Healthcare Frank Ingari
predicted that practices can complete the transition from fee for services to outcomes based care in two to three years. What this will take, in part, is a change in the doctor’s role.
“Our model today is a reactive patient presentment mode. The doctor sits and patients present. There’s a ton of people who don’t present until they show up at the ER. We need a model that flips that around where the provider community is outreaching,” Ignari said.
There is a lot of talk at the Innovation Summit at how new technologies might inspire this kind of engagement. Dr. Brian Prestwich of the University of Souther California said population management software now allows him to walk into his office in the morning and zero in on which the 3,000 patients in his system he’ll be taking care of.
Chief Medical Officer of Aetna Lonny Reisman gave an example of how these technologies give doctors the capability to identify groups of patients who need certain treatments ― but they don’t guarantee that patients will get those treatments. He told a story of how a group of providers identified patients who were in need of drugs after suffering a heart attack. They ordered the drugs and gave them to the patients for free. They later found that half of those patients didn’t take those drugs.
“Without community, without support with other sorts of incentives that are frankly beyond what I’m able to conceive of, there are clearly more partnerships, more levels of collaboration that are going to be needed in order for us to optimize the value that theses technologies can ultimately bring,”Reisman said.
A change in culture is needed on the patient side. But it’s also needed on the provider side as they move from thinking in terms of transactions to thinking in terms of outcomes. CEO of ChenMed Christopher Chen said that over the years his company has been able to scale culture relatively effectively. But there’s a worry that the culture change won’t be in sync with the policy changes that will come in the next few years with the Affordable Care Act.
“You have a doctor today practicing in a fee for service environment and he is engrained to think in a fee for service pattern. It’s amazing,” Chen said. “A lot of them say the idea is great, but I can’t wrap my entire head around it because I’ve stuck in a specific way of practicing for a number of years.”
Moderator Chief Strategy Officer of West Wireless Health Institute Mohit Kaushal ended on an optimistic note saying he thinks these efforts to innovate around technology and change culture will work. All we have to do is do the things we say we’re going to.
Case Studies in Primary Care Innovation
Dr. Lonny Reisman, Chief Medical Officer, for Aetna described how Aetna is leveraging HIT solutions to facilitate improved care delivery. Their acquisition of Medicity has allowed them to create an health information exchange to power functionality needed to create ACOs, specifically via personalized health records, clinical analysis, care management, population management, and risk management. While their health IT solutions have helped them achieve a reduction in acute admissions and hospital bed days, he cautioned the audience to recognize the limits of health IT. In a recent study publish in NEJM, providing access to post-heart attack drugs at zero copy increased compliance to only 49%, highlighting the importance of taking a broad view of patient support.
Frank Ingari, President and Chief Executive Officer, Essence Healthcare, described how a collaborative payer models and integrated provider associations have achieved decreased hospital bed use and readmission rates. Data (and pay for performance) have reduced information asymmetry, adverse selection and denial of care rates. By providing technology and data to providers, Essence is allowing physicians to engage in continuous learning and identify actionable information based on their performance.
Dr. Chris Chen, founder of ChenMed, showcased how his organization turned its head to the sub-optimal care resulting from fee-for-service and instead pursued a model of full global risk. By focusing on improved physician culture (small panel size, frequently panel review, open discussion of practice patterns and outcomes among all physicians) and facilitating rapid cycles for technology innovation (such as the creation of a pharmacy robot delivering prepared prescriptions directly to the exam room door) ChenMed has achieved admirable outcomes and satisfaction scores among its enrollees.
Dr. Brian Prestwich, Assistant Professor of Family Medicine at the University of Southern California, highlighted the four pillars of primary care – relationship over time, access, comprehensive care and coordinated care. He provided examples how his clinic has drawn on models piloted by GroupHealth to improve care. A new worksheet for well child checks has increased his clinic’s structured developmental screening rate from 10 to 90%. Use of occupational therapists has allowed him to embed wellness coaching into his clinic. His call to action? “As a doctor in the trenches please get out there to agitate for better health information technology, and develop integrated health systems that will help us get the job done.”
David Krichhoff, CEO of Weight Watchers, described the R&D Weight Watchers has invested into developing and validating consumer-facing wellness technologies. He called on the integration and use of wellness services in achieving behavioral change among patients. As an example, the NHS in the United Kingdom purchases vouchers for Weight Watchers, which it then provides to doctors so doctors can prescribe and refer patients to Weight Watchers.
Transformation driven by a tide of grassroots innovation mojo has already begun
Rick Gilfillan Director of CMS Innovation Center opened his speech with the declaration “its a wonderful time to be in health care and to be a health care innovator”. He defined innovators broadly, calling on all business people, investors, entrepreneurs, health care providers, and patients who have the passion, creativity and courage to help America achieve better health, better care, and reduce costs.
Already the CMS innovation center has been testing and piloting new models of care delivery involving both technology and business model innovation in sites across the country. Examples? Primary care demonstration sites at federally qualified health centers in 44 states, a new focus on dual eligibles, bundled payments for care, pioneer ACOs, the Innovation Advisors Program, the Million Hearts Initiative, partnership for Patients, among more…
These sites are simultaneously laboratories for the development of best-practices as well as demonstration projects to show our country what is possible when providers and payers begin thinking about care provision differently.
Todd Park, Chief Technology Officer, U.S. Department of Health & Human Services, followed Rick Gilfillan and underscored the importance of data access in achieving CMS’s three-fold goals of better health, better care, and lower costs. He provided four examples of how HHS is helping stakeholders to access, analyze and use data to drive innovation while respecting and rigorously protecting beneficiary information:
1. Blue Button Initiative: Over 500,000 vets, military personnel and Medicare beneficiaries have used this technology to download electronic copies of their own health information. The private sector is now following suit with insurers and HCOs offering their own blue button analogs.
2. Pioneer ACOs: CMS is providing ACOs with claims data on participating patients so that they can benchmark their performance and pinpoint gaps in care.
3. Physicians: Claims data for qualified public / private sector companies will help them assess physician practice patterns and assess provider performance.
4. HHS health indicators warehouse: Community-level health data will help communities assess the health status of their constituents and identify areas for intervention.
He concluded: “There is no problem that Americans can’t invent themselves out of…Transformation driven by a tide of grassroots innovation mojo has already begun.”
“We have to know what we mean by great care, measure it, innovate it and then implement it,” author of The Checklist Manifesto and surgeon Atul Gawande said.
In the beginning of his keynote, Gawande said that cost has put the American health care system in the greatest crisis of its existence. Yet, Gawande didn’t talk much about cost the rest of his speech. He suggested that the health care system first needs to define exactly what quality care is before moving onto a discussion about cost.
Creating innovations around data is one way he suggested that the health care system can start to recognizes its weaknesses.
“We know more about how the crops are doing and how the cows are doing than we know about how the human beings are doing.”
After innovation comes implementation and that’s where physicians will resist change, Gawande said. Doctors are too used to doing it on their own, acting as cowboys. But things have gotten too complicated in the world of modern medicine.
“The accumulation of knowledge in science is more than anyone of us can handle anymore,” he said.
The system needs encourage physicians to transition from one-man shows to a members of a pit crew.
Gawande ended saying that in the political world, we think we need to fix all of our problems in two years. Gawande said that we have longer than that. But we need to get going on bending the cost curve now.
Welcomes & Intros
Don Casey, Chief Executive Officer, West Wireless Health Institute, Susan Dentzer, Editor-in-Chief, Health Affairs, and Marilyn Tavenner, Acting Administrator, Centers for Medicare & Medicaid Services welcome an audience of 1,000+ live and 1,000+ live-stream attendees.
Rapid fire calls to action emphasized the urgency of health care disruption given out of hand costs.
Don Casey stressed a need to achieve both improved outcomes and value, and called upon CMS to take advantage of the digital revolution to “jailbreak” healthcare. 35% of all health care is already paid for by CMS so the identification of key, valuable innovations can and should be rapidly scaled.
Susan Dentzer called on all Americans to work hand in hand to create a “health care system that is built to last”. Health care might have been the “elephant in the room” during this week’s “State of the Union” and in the following Republican response, but Dentzer emphasized that health care is rooted in the “American spirit” and not “blue or red, but comes in purple”.
Marilyn Tavenner rattled off an impressive list of accomplishments by in 2010 and 2011 including closing the donut hole and creation of high risk pools. Looking forward to 2012 and beyond, emphasis is on shifting to delivery system innovation and public-private partnerships to better coordinate care and improve quality.