By Kent Bottles, MD

Anyone who is concerned about the future transformation of the United States clinical delivery system should pay attention to the Care Innovations Summit. The selection of presentations as well as the content that was discussed says volumes about where CMS believes payment is headed. Speaker after speaker stated that decreasing the per-capita cost of health care and increasing the quality patients receive is the dominant political, social, and economic issue for all Americans.

Marilyn Tavenner, the new Acting Administrator for the Centers for Medicare and Medicaid Services, outlined what she saw as the major accomplishments of the past few years. Her list included providing partial relief for 3.8 million seniors who hit the prescription drug “doughnut hole,” creating high risk pools for 45,000 Americans, creating a consumer website, allowing young adults to stay on their parents’ health care insurance until age 26, eliminating denial of coverage for patients with pre-existing conditions, eliminating lifetime and annual health care insurance maximums, increasing the coverage of many prevention measures, creating pilots to explore how to base payments on quality not volume, and getting the Innovation Center up and running.

Atul Gawande, MD, the Harvard surgeon and New Yorker author, presented the morning keynote. Gawande, the author of three books on health care (Complications, Better, and The Checklist Manifesto), said the “cost of health care is destroying the American dream.” In Massachusetts the state government sent nearly a billion dollars to local schools to pay for smaller class sizes and better teachers’ pay, but every dollar was diverted to covering higher health care costs. For each dollar added to school budgets, the costs of teacher health benefits consumed $1.40.

Gawande listed three causes of our current health care problem: business interests, government bureaucracy, and the sheer complexity of delivering clinical care in a broken system. He focused on the last of these causes and noted that there are at present 13,600 diagnoses, 4,000 medical procedures, and 6,000 medications. In 1970 the average patient saw two physicians for their medical conditions; today the average patient has more than 15 physicians consulting on their care. He also stated that the health care system “trained and hired physicians to be cowboys, when what we really need are pit crew team members.” He is also hopeful because the health care systems that have the best results are not the most expensive.

The most successful health care systems utilize three skill sets that many in health care ignore: 1) Recognizing success and failure by using data. He observed that our current use of data is like “driving a care without a speedometer that only tells us how fast the other cars were going four years ago.” 2) Devising solutions by thinking like other fields that are high risk and high failure. His example was the checklist. 3) Overcoming the culture of resistance among physicians by implementing and spreading the solutions. He thought that medical schools have not done enough to install the values of humility, discipline, and teamwork in their graduates. He concluded by saying there is a battle for the soul of medicine and that we only have eight to ten years to solve our national problem.

Rick Gilfillan, MD, Director Center for Medicare and Medicaid Innovation, and Todd Park, Chief Technology Officer for the US Department of Health and Human Services, gave an overview of payment and data programs being championed by the Innovation Center. Parks described data “as rocket fuel for innovation” and presented four ways that CMS was going to be more transparent about data: 1) the Blue Button program where 500,000 veterans and Medicare patients have already downloaded their clinical data; 2) Data for ACOs program will provide aggregate reports for this new payment vehicle; 3) Medicare Data Sharing; and 4) Health indicators warehouse project.

Mohit Kaushal, MD, MBA, Executive Vice President and Chief Strategy Officer of West Wireless Health Institute, moderated a Care Delivery/Primary Care Innovation Case Study Panel. The panelists included Christopher Chen, MD, CEO of ChenMed, Frank Ingari, President and CEO of Essence Healthcare, Brian Prestwich, MD, Professor at USC, Lonny Reisman, MD, Chief Medical Officer of Aetna, and David P. Kirchhoff, President and CEO of Weight Wathers.

A number of conclusions were reached. There is a continuum of payment reform from fee-for-service to pay for performance to shared risk to full capitation, and different payment models work best for each step of the continuum. They also agreed that full capitation is coming. Dr. Chen and Mr. Ingari noted that physician culture must be changed and that you cannot manage providers in two cultures at the same time (fee-for-service vs. capitation). Dr. Prestwich emphasized the importance of using alternative providers to physicians and nurses; he uses occupational therapists and social workers to provide many transitions of care services. There was general agreement that current versions of electronic medical records (EMRs) do not provide usable data when and where it is needed to be successful under capitation. Dr. Reisman emphasized the need to activate patients and noted that even when Aetna paid for post myocardial infarction medications, half of the members did not take them. Mr. Kirchhoff related the success of a United Kingdom program where the NHS had physicians prescribe the weight watchers program to obese patients.

Dr. Gawande moderated a Care Delivery/Chronic Disease Innovation Case Study Panel. Panelists included Kenneth Coburn, MD, MPH, CEO of Health Quality Partners, Alan Hoops, Chairman and CEO, Wellpoint/CareMore, Debbie James, Vice President of Healthways Fitness Division, and Mary Naylor, PhD, RN, Professor of Nursing at the University of Pennsylvania.

All the panelists reported on their successful programs for taking better care of seniors with chronic diseases. Since the Congressional Budget Office reports that 5% of Medicare beneficiaries account for more than 43% of costs, and 25% account for 85% of Medicare spending, such programs will be essential for us to lower per-capita costs and increase quality. Ms. James reported that relatively simple steps (local gyms, special welcoming coaches at the gyms for seniors, targeted mailing and phone calls to patients with chronic diseases, and educating physicians to encourage fitness by giving a prescription to the gym) have increased participation in the Silver Sneakers fitness program. Dr. Coburn of Doylestown, PA uses a Sutter Health questionnaire to identify patients who would benefit from his nurses and their 35 transitions of care tools. Mr. Hoops uses predictive modeling tools and retrospective look backs of expensive patients to identify patients who need to be removed from the primary care physician panels and managed by special “extensivist physicians.” Professor Naylor emphasized the importance of specially trained nurse practitioners in delivering post discharge transitions of care. Naylor’s approach is nicely summarized in a recent Health Affairs article (http://content.healthaffairs.org/content/30/4/746). Gawande shared some of his observations about Dr. Jeffrey Brenner’s work in Camden, New Jersey where 900 people in two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health care bills (http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande). Gawande in his keynote also shared CMS data that indicated that patients with heart disease, chronic kidney disease, diabetes, COPD, depression, rheumatoid arthritis, dementia, stroke, osteoporosis, and cancer are candidates for this transitions of care approach.

Simmi P. Singh, Senior Advisor, Health Innovation, Office of the Secretary, Department of Health and Human Services moderated the afternoon panel Cancer: Journey Toward Better Health, Better Care, and Lower Costs Case Study. Panelists included Amy Abernathy, MD, Associate Professor, Duke University, Amy Berman, RN, Program Officer, John A. Hartford Foundation, Jeffrey Elton, PhD, Co-Founder, Kew Group, Bruce Johnson, MD, Head of Thoracic Oncology, Dana Farber Cancer Institute, and Chris Olivia, MD, Board Member, Eviti.

Dr. Johnson discussed how genetics can subdivide adenocarcinoma of the lung into different types with new treatments. When genotyping an adenocarcinoma identifies that the driver mutation for that tumor is the EGFR gene, oncologists have had successful clinical responses by treating with the oral medication Gefitinib. Other adenocarcinomas of the lung reveal that the driver mutation is the Alk+ gene that responds to the oral agent Crizotinib. In the past these lung cancers were all lumped together as adenocarcinoma as revealed by light microscopy. Drs. Elton and Olivia described competing approaches where lung cancer patients could be treated in the community by general oncologists, buts still receive the latest evidence based medicine treatments such as those described above for lung cancer. I was a little surprised that none of the panelists mentioned that 60% of melanoma patients have a specific point mutation (V600E) in the driver mutation BRAF gene that can be treated by an orally active BRAF mutation directed drug that specifically binds the mutated protein with an 80% response rate. There was also discussion of the need for new business models; in the United Kingdom the NICE has approved some of these expensive cancer drugs as long as the company gives the NHS a rebate for the patients who do not respond.

Susan Dentzer, Editor-in-Chief of Health Affairs, interviewed Jonathan Blum, Deputy Administrator and Director for the Center of Medicare at the Centers for Medicare and Medicaid Services, Cindy Mann, Deputy Administrator Director for the Centers for Medicare and Medicaid, and Dr. Gilfillan in a closing session. She said that if the transformation of American health care was a soup it would need the following ingredients: people who can overcome the culture of resistance by imagining new roles for patients, physicians, nurses, allied health professionals, employers, and government; payment such as capitation that incentivizes prevention over volume of services delivered; delivery system changes so that team work and coordination of care is emphasized across the continuum of care; culture changes so that fixed mental models of how the health care system works are challenged; technology and data so that providers can have real time evaluations of how delivery system changes are really succeeding or failing; evidence based medicine guidelines and perhaps in the future computer simulation models such as Archimedes; and strategies so that the successful changes are spread and scaled.

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billionhealth care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his blog, Kent Bottles Private Views.