Thursday, June 2, 2011

Is Medicare really capable of innovation?

This question has to be asked, because health policy gurus are looking to the new Center for Medicare and Medicaid Innovation (“the Innovation Center”), created by the Affordable Care Act, as being the principal driver of innovative delivery system reforms to “bend the cost curve”— but skeptics wonder if it can live up to its billing.

The Innovation Center’s website says all of the right things:

“The Innovation Center has the resources and flexibility to rapidly test innovative care and payment models and encourage widespread adoption of practices that deliver better health care at lower cost.

Our Mission: better care and better health at reduced costs through improvement. The Center will accomplish these goals by being a constructive and trustworthy partner in identifying, testing, and spreading new models of care and payment. We seek to provide

- Better health care: by improving all aspects of patient care, including Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity (the domains of quality in patient care as defined by the Institute of Medicine).
- Better health: by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventive care.
- Reduced costs: by promoting preventative medicine, better record keeping, and improved coordination of health care services, as well as by reducing waste, inefficiency, and miscommunication. These efforts will reduce the national cost of health care and lower out-of-pocket expenses for all Medicare, Medicaid or CHIP beneficiaries.”

This mission statement echoes CMS’ Administrator Don Berwick’s view, quoted in the Health Affairs blog that health care transformation “won’t yield to a massive top-down national project.” Instead, Berwick argues that, “Successful redesign of health care is a community by community task. That’s technically correct and it’s also morally correct, because in the end each local community – and only each local community – actually has the knowledge and the skills to define what is locally right.”

And it is encouraging that the Innovation Center has also recruited a top-notch – but small – staff that includes doctors who are grounded in the real challenges of private practice medicine and experienced in community-based innovation, including two masters of the American College of Physicians, Dr. Rich Baron and Dr. Nancy Nielsen.

Yet, skeptics wonder whether the Innovation Center can deliver on Dr. Berwick’s recognition that “in the end each local community, and only each local community, actually has the knowledge and skills to define what is locally right.” Such skepticism has increased with the publication of the Medicare’s proposed rule on Accountable Care Organizations (which came out of the Innovation Center). For instance, Vince Kuraitis in the Health Care Blog writes that “CMS loses points for micromanagement and a controlling mindset” even as he expressed “kudos to CMS for a surprisingly aggressive and well reasoned ACO Rule.”

Even if the Innovation Center wants do the right thing by supporting bottom-up innovation, I wonder if others in the administration will get in its way. The White House’s Office of Management and Budget, and Medicare’s own independent actuary, seem to be fixated on only allowing money to be spent only on projects that can be guaranteed to produce measurable savings. By law, they will have to sign off on any disbursement of funds from the Innovation Center. Such insistence on unrealistic guarantees of savings may be why the bar for participation was set (many would say unrealistically) high in the ACO proposed rule.

And even if the Innovation Center is able to find the right balance between supporting community-based innovation and ensuring that taxpayers’ dollars are spent prudently, will Congress take away it’s funding? Some key House Republicans have promised to go after the Innovation Center’s dedicated funding, labeling it a “10 billion slush fund.”

Yet it is important that those of us on the outside do everything we can to help ensure that the Innovation Center lives up to its billing. The one thing that liberals and conservatives should be able to agree on is that without substantial reforms to reduce per capita health care spending, the country will not be able to improve its fiscal health. The Innovation Center offers perhaps the best chance for Medicare to support community-based innovation to improve outcomes and lower costs, and if it fails, the likely alternative will be more top-down price and capacity controls and explicit rationing of care.

Today’s question: What do you think Congress and the Medicare program can do to promote innovation in delivery system reforms at the community level, and what shouldn’t they do?


Steve Lucas said...

I personally do not see this top down approach working and do see a large amount of money being spent on pointless activities.

An example is this old song:

“Better health: by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventive care.”

People like fast food, computer games, big screen TV’s, and anything else that does not require getting off the couch.

During the Depression putting out a big meal was a sign of prosperity. Almost all of the men drafted in WW II were underweight. They brought back the eating habits that we live with today.

Think Europe has the answer? No. On our last trip to Paris in March my wife and I were stuck by the weight gain of the young people. Café’s are dying, and McDonalds and other fast food places, are taking over the empty space.

People enjoy a sedentary lifestyle. Forget about taxing fast food. You are punishing an industry that has become so efficient it can deliver calories cheaper than a person can produce themselves by buying and preparing the food at home.

Any changes in the population’s health may come about with a more relaxed interaction between a doctor and their patient. This takes time. Telling a person they are fat, and the nurse will be in with a diet will not produce any results.

This comes down to the same old same old, a doctor having a trusting relationship with a patient and the time to have a real conversation. Until then, our fire stations will continue to stock those 1,000 pound gurneys.

Steve Lucas

ryanjo said...

The initiatives that CMS can and should be doing, they have not. Why does a simple change of address trigger a 2 month freeze of Medicare payments? Why does the mandated CMS form to request a non-formulary drug require a patient's height & weight, and dated in 2 areas? Does anyone expect the clerks that review the form to analyze dose/weight relationships?

Fact: CMS is an uncontrolled bureaucracy with a proven record of wasting tax money on trivia, while ignoring widespread fraud. There is nothing in the "DNA" of this organization which allows for any "better care and better health at reduced costs through improvement". Drs. Baron and Nielsen have unwittingly been recruited by Don Berwick for his PR program to mask his (to this point) total failure to accomplish anything at CMS except photo ops. The Republican Congress is just a convenient excuse for continued failure.

Chris said...

The Congress must first collaborate with the private health care providers to come up with a feasible solution to Medicare problems.

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