Medicare and Innovation? How About Get Out Of The Way?

The Disease Management Care Blog hasn't been much of a fan of the Commonwealth Fund. While they say they're working toward a high performance health system, the paranoid DMCB suspects their progressive agitprop is really all about promoting beret-wearing physicians who ride motor scooters to government-run clinics where they pleasantly pass the day using electronic health records to document preventive services.

So it was a nice surprise when it came across this very downloadable Commonwealth Fund Report by Mary Takach, Anne Gauthier, Kristin Sims-Kastelein, and Neva Kaye titled Strengthening Primary and Chronic Care: State Innovations to Transform and Link Small Practices. The report is 67 pages, but your trusty DMCB is pleased to offer up a condensed version for our mutual learning pleasure.

Here's a teaser quote from the report that contrasts with the current health reform orthodoxy:

"....because health care delivery is local, the federal government is neither designed nor equipped to devise and administer the specific actions states and private sector partners are undertaking."

The authors conducted "semi-formal interviews" with a convenience sample of health care leaders from States with a reputation for successful reform efforts in the areas of primary and chronic care. The key words were "initiatives," "consortia," "networks," "linkages," "programs," "task forces," "collaboratives," "frameworks," "pilots," and "communities." The States were Colorado, Michigan, North Carolina, Oklahoma, Pennsylvania and Vermont.

What worked? An ongoing, multi-year and flexible commitment to:

Payment incentives to reward outcomes. Examples included shared savings in Pennsylvania, medical home payments in Michigan and fee for service combined with tiered and risk-adjusted monthly payments that were aided by transitional payments in Oklahoma.

Infrastructure support such as sponsoring expert assistance, convening meetings and supporting shared services in the areas of teaming, learning, information exchanges, registries, e-prescribing, EHRs, hosted web portals, funding, loans and getting insurers to streamline their interactions with providers. Examples included the funding of community-based medical home "navigators" in Colorado.

Leadership leading to multipayer agreements. Examples include activist governors in Vermont and Pennsylvania as well as aggressive state agencies in Michigan and Oklahoma. One interesting tactic involved the State "brokering expenses" by collecting office practice tax returns and practice expense reports to calculate the fraction each insurer had to pay for any shared services. States not only have a powerful bully pulpit, but can leverage CHIP, Medicaid and managed care contracting to explicitly support medical homes. It also occurred to the DMCB that Governors and state agencies can shield the insures from being accused of anti-competitive behavior.

Information feedback and monitoring such as public reports aimed at test duplication, after hours access and preventive services versus benchmarks.

Certification and recognition that combined national programs (such as the NCQA) with local State-run audits (examples included Oklahoma and Pennsylvania).

The details underlying each of these five ingredients turned out to be very local and reflected different communities that were quite diverse. In contrast, the federal government's size, distance, statutory limitations and an emphasis on large practices make it practically impossible for it to perform well in settings dominated by smaller physician-owned clinics.

That doesn't mean that there aren't things that the Feds can do to help:

1) Medicare needs to pay its fair share and stop cost shifting here too.

2) The meaningful use criteria in HITECH are good. Don't mess this up.

3) Reconsider the use of demonstrations. They're too slow and often don't result in any policy changes.

4) Payment reform and grants are necessary but insufficient when it comes to getting the attention of primary care physicians.

While the DMCB has always been cautious with qualitative research like this, it finds the report credible. While the authors didn't ask about disease management, the important message is that there are States that are already light years ahead of the Federal government when it comes to reviving primary care, promoting medical homes, combining the key words above with population health management and meaningfully reforming how health insurance functions. While Medicare has committed itself to "innovation," the message here is that CMS may do better as a learning organization that catalyzes and supports the good work that is already underway.

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