Healthcare Quality Summit: State-Federal Collaboration & Public-Private Partnerships (Part 2 of 2)

Uploaded by USGOVHHS on 07.10.2010

bjbjLULU My question is in addition to touting what s being done and the exciting work that
you re doing in each one of your states, how do we figure out as a community, how do we
work as ambassadors and evangelists to states where the person sitting in Mr. Allison s
spot might be a little bit more worried about kind of, some of these partnerships or going
to private payers who might not be as enthusiastic as the ones in Vermont and trying to bring
those folks together. What have folks experience been in trying to spread the gospel, so to
speak? Craig Jones: s a great question. I think there s been a lot of levels t to take
this on and one actually goes back to the talk that Dr. Berwick just gave. So as part
of the reforms, we re beginning to work with more and more collection of other states who
are also doing multi-insurer payment reforms, Maine being one and there s others where we
re starting to look at common assessments across the states and shared learning interactions.
So there s, we institute -- we re trying to do it in advance -- so there s -- we put these
multi-insurer payment reforms in place, and medical homes, advanced primary care practices
-- in our case, community health teams as all of this begins things to roll out. Well,
if you really think about it, it s an extraordinary opportunity because every one of these states
that s pushing for new models of primary care and prevention and coordinated services is
bringing about some pretty common principles. The principles are very similar but the strategies
are different. It s an ideal opportunity for learning variance. It s an extraordinary opportunity,
so if we have common assessments, the common data from Medicare and Medicaid and insurers
and other sources. In fact, for example, there are a number of states have the same multi-payer
database, such as Maine and Vermont and New Hampshire; you actually are beginning to build
the opportunity for comparative effectiveness or comparative assessments across state lines.
I think that is a critical place to start in working across state borders. Male Speaker:
Just to add briefly to that. Craig, that was a great summary. There is lots of discussion
between CMS and the other federal agencies about what infrastructure would be useful
to not just disseminating, but scaling up, doing it a little faster. I don t think we
really have the answer yet but I m sure hopeful that [unintelligible] start seeing that. I
would add, though, that this is the place for the associations, for the MMC, the Osteopathic
Association, to share, because often, you ll find the academic health centers in there
somewhere helping drive that. And this is probably not one dissemination strategy but
a couple dissemination strategies simultaneously. Woody Eisenberg: Hi. My name is Woody Eisenberg.
I m the chief medical officer for Medco, which is an [unintelligible] manages Medicare programs
and I m also a member of the board of directors for PQA. So I m very interested in figuring
out where the role of pharmacy fits in these partnerships that you re discussing. Lloyd,
during your comments, you talked about a very successful asthma program for the disabled,
mentioned that it didn t save money because they were using more drugs, which was a good
thing in this kind of situation. [speaking simultaneously] The drugs might bring down
the total medical costs. And Andy, you mentioned the impact that [unintelligible] spending
has because of shifting spending over from Medicaid programs -- savings for spending
over from Medicaid programs to Medicare, and certainly that applies also to the [unintelligible]
benefit. So I m interested for any of your thoughts on where the world of pharmacy fits
into your partnerships. Male Speaker: ve actually had some great discussions with Medco about
that as you probably know. [laughter] So let me just go from Medco to medicines, broaden
it, and that is one of the areas in which we, at least the team I ve been part of, have
been slower to figure out how to do effectively, and really successful as we have has been
figuring out how to get appropriate prescribing directions for patients and providers. Just
take a case in point. Most of us have no idea that roughly half the prescriptions we prescribe
are never filled. We just keep writing more and more expensive drugs because of all the
lack of efficacy of the drugs the patient never got. So we have in some ways to link
that and to have that -- to get appropriate advice on what the patient is actually taking
has really been helpful, and especially in some of our folks that have the most severe
AIDS and chronic disease and all the issues about drug-drug interactions and genetic variations
are [unintelligible]. Lillian Shirley: I just -- you know, we run a large system, a large
safety net system as well and also jail health so I m not against giving less drugs because
I figure that s a good thing if you re going to stay out of the hospital and you re going
to not need cardiac bypass surgery because you re on your aspirin and you re on your
whatever regime. However, you know, I do think that there needs to be, as I say to our pharmacists
all the time, there needs to be forged a better partnership between the primary care prescribers,
particularly the chronic disease area, and in the mental health drugs and the patient.
And, you know, I don t know where that nexus is but I do know that we have external providers
who every time a kid comes in the jail they want another psychotropic drug because it
was the latest one or something. Maybe that s because they didn t fill the prescription.
I don t know. This is something I would take at home -- thank you very much. But I think
it s a more fundamental problem of what is the role of pharmacology in achieving the
outcome goals and [unintelligible] integration. And I think that, you know, in Oregon, we
have a standard list, you know. If you go outside of that list and prescribe something
for the Medicaid patient, it s not covered because there s not enough evidence or it
s not enough different than the outcomes that you re seeing. You know, that might not work
in other parts of the country, but it s very hard to get the private providers and the
commercial providers to accept that kind of community standard of care. But for the Oregon
Health Policy Board, that s one of the drivers with the Oregon Health Authority to make that
acceptable level. I mean, you can -- you know, if I have the money, I can buy whatever I
want. But in terms of the system criteria, we re going to try and standardize it but
we do need to bring people into the conversation about where is that nexus? That needs to happen.
Andrew Allison: If I could add just one point to that and it is that states are over-matched
on the question that I think that Lillian just posed in trying to make sense of how
do you use and how to prescribe, pay for, in particular, behavioral health pharmacy
products. And we have tried to do that in Kansas. We tried to make some sense of how
to use them but have found that, you know, we re just practically over-matched. I think
the federal government is going to have to take a stronger interest in answering that
question. Richard Frank: This gentleman over here and then? [speaking simultaneously] [laughter]
Female Speaker: m [unintelligible] from the Robert Wood Johnson Foundation. Tomorrow,
the Institute of Medicine is going to release some recommendations related to transforming
the future of nursing. I m interested in hearing your experience or the experience in your
states of partnerships between the physician community and the nursing community and what
can you potentially see going forward for these two groups to work together to try to
improve access to primary care. Craig Jones: So in Vermont, nurses are, of course, a critical
part of this foundation of advanced primary care and well-coordinated health services.
You heard, I think, Dr. Estes this morning on the opening panel for Fletcher Allen and
our academic medical center talk about the team-based approach that s being built there.
And so you have teams at several levels. You have teams within practices and then you have
in our case teams across practices: the community health teams, nurses, social workers, multi-disciplinary
teams that are supporting practices. And nurses have a lead role at every one of these levels,
being an advanced practice nurse running a primary care practice and help run the operation
with inter-practice settings. Nurse coordinators tend to be running the community health teams
with all the other folks that are involved. So they have a pivotal role in this and it
s really critical because physician training is quite different, as everybody probably
knows, than nursing training. Nursing is part of their training. They learn how to run things.
They learn how to run floors. They learn how to run areas of hospitals. They learn how
to run practice clinics in clinic settings. Doctors don t. In fact, they re constantly
being re-directed to try and understand how to run things. Nurses are critical. If we
re going to talk -- the reason I m bringing that up is that if we re going to talk about
systemness, talk about bringing systemness to a non-system, nurses are critical. They
re critical at the care delivery level and at the coordination level and population levels.
Noel Clark: And at the community mental health center, we have plenty of people who are willing
to run things. [laughter] What we don t have are people who -- nurse practioners and advanced
practice nurses who can augment what s happening in the community mental health center. But
psychiatrists in New Mexico are very, very difficult to recruit and we tease about it
but they can -- they re a [unintelligible]. We cannot generate in revenue what it costs
to put a child psychiatrist to work, either through local [unintelligible]. The only way
we can make it work and have any luck doing so is a telehealth connection in partnership
with the University of New Mexico to put people in front of TVs. What we need is encouragement
maybe with the health -- what is it? Health corps? [speaking simultaneously] National
Health Service identifying with states what actual providers we need in our community
and we can -- one of the partnerships that doesn t exist is linking people with the National
Health Corps to providers who will assist with the transition, with helping get those
people in our community. Doctors -- we have one and a half FTEs of docs and one of them
works in Virginia and does telehealth from there. The other one lives in Albuquerque
and does telehealth from Albuquerque. Three hundred miles between Albuquerque and Carlsbad.
We need nurse practioners in the field who are trained with the psychopharmacology who
are willing to go to work and maybe not so much run a clinic but the patients -- we have
access standards where we believe that engaging a customer within 10 days of the original
assessment to [unintelligible] management is essential to keeping that customer in care
and if we had the staff, we could do it. But what s holding us back in meeting our access
standards is access to the professional. Richard Frank: ve been very patient. Lorrie Kaplan:
Well, my patience has been rewarded because -- [laughter] Because I had a prepared question
but you just fed me a beautiful opportunity so I could [unintelligible]. My name is Lorrie
Kaplan. I m executive director of the American College of Nurse-Midwives. And so my colleague
just mentioned the brilliant report -- well, we hope that it will be brilliant -- that
s coming out this week. Long awaited; I ll say it that way. But I do have to say also
that one of the biggest issues we have on workforce and being able to address the very
challenges you just mentioned is the fact that in many states, many practioners, like
nurse practioners and in certain [unintelligible] nurse-midwives, are not able to practice up
to the full scope of their education. And I m sorry to bring anything divisive into
this, but organized medicine is fighting these practioners every step of the way in most
states to keep that from happening. So I think we -- and National Association of Community
Health Centers and academic medical centers have produced brilliant -- these really are
brilliant reports; I ve already seen them -- about meeting our primary care workforce
challenges and they really do a state-by-state analysis where they show that in those states
where the scope, where these practioners are able to practice at their full scope, we can
attract those folks. And New Mexico happens to be the leading state in nurse-midwife attended
births with fantastic outcomes. So that s my segue; sorry. My soapbox was over to maternity
care, which you would associate with midwifery but we do primary care as well. Combined [unintelligible]
for maternity care you can look at both infant and maternal costs are the number one cause
of hospitalizations in this country and Medicaid is the primary payer. So we would think that
maternity care would be a really obvious opportunity for these multi-state [unintelligible] efforts
and some really fine work as been done in that area to identify specific strategies
where you can lower costs and improve value maternity care. Where s the uptake and have
any of you had experience working directly in that area? Thank you for your patience.
Elizabeth Mitchell: ll jump in quickly. One of the approaches that we re taking as we
ve launched these pilots is to actually look at local data, because variation, as we all
know, is alive and well. So what are the opportunities in your area? And lo and behold, maternity
is a major cost driver for a lot of purchasers. We didn t even know this because it s not
through Medicare data for very clear reasons [unintelligible] -- [laughter] So we are absolutely
going to be looking for pilots around there and we have new partnerships emerging where
there s a huge opportunity to really pilot a bundled unit around maternity care. It s
a very clean, bundled, as it were; you could get started there and then sort of back it
out maybe to a population health data, local payment, because you come from the first stage
to all the way to the delivery. So I think it s a prime area for program highlighting
and system redesign and it is now emerging in the commercial data as a clear priority.
Richard Frank: Okay. Two final questions, one here and one there; two very patient,
gentlemanly people. Mike Kapsa: ll try to make this really brief. My name is Mike Kapsa.
I m with the coalition of unions that represent employees at Kaiser Permanente. We represent
about 100,000 employees, nurses, patients, service workers. And my question is really
just came out of the last two questions. Really it s about partnership at the point of delivery,
partnership among caregivers, what we at Kaiser call the employee-management partnership.
I wanted to get feedback from you on that. Where, at Kaiser, the workers at Kaiser have
committed with management and the physicians to deliver high-quality care, productivity
improvements in a team-based environment. So it s a learning environment, what we call
unit-based teams. So now at Kaiser, we have almost a 100,000 workers involved in the wards,
at the departments in what we call unit-based teams in a learning environment that deliver
high-quality care. So I just wanted to get your sense of another partnership that is
between basically amongst the caregivers, all of the caregivers, at the front lines
deliver the care. Thank you. [speaking simultaneously] Lillian Shirley: s a medical home, basically.
It s a medical home and, you know, I would just like to say I am a nurse. But you know,
when we moved to the medical home, with a lot -- inter-collaborative and a lot of other
payment help from our Medicaid payer in the state of Oregon in my own system, what happened
was the nurses got turned loose, the teams really begin respecting each other. We ve
done some evaluation. I mean, what you re talking about this -- we can talk about teams,
but when you have an outcome that they re all accountable for, the physician is very
often going to listen to the CMA because she s pointing out that he forgot [unintelligible]
or whatever [unintelligible] you know, talk to Ms. So-and-so about something. So I really
think that moving to these system changes answers a lot of the value principles that
we have about how we want to do our work in health care. And that s an underlying platform
I think that we can stand on together. Elizabeth Mitchell: Can I just add very briefly that
there s a medical home pilot site we have where [unintelligible] among staff fell from
20 percent to two percent because they re actually happier in this team-based environment
if it s done well. So I think it can be positive for the whole team. Richard Frank: We --
because of your enthusiasm, we are just about out of time, so what I d like to do is just
give you the pleasure of the last shot. [laughter] And then if there are direct answers from
the panel, that will be fine, and then I think we re going to have to call it a wrap. Michael
Painter: Richard, thank you for the opportunity. I m Michael Painter from the Robert Wood Johnson
Foundation. I m sorry there are two of us but you can tell how we at the foundation
are really interested in this local partnership and collaboration. I work at the foundation
on our quality and value investments. I spend most of my time aligning forces for quality,
which is really focused obviously on a lot of things that you guys are talking about.
I wanted to take though -- everybody talked about the exciting times, which it is, and
this is a terrific panel. I really appreciate it. I was fascinated to listen to it. But
I wanted to sort of take the flip of the excitement and all this sense of opportunity and a couple
of you alluded to some of the anxieties that might be part of that flip. Elizabeth, you
said, Well, we don t want one-size-fits-all. Lloyd, you said, Help us, or maybe even don
t get in the way, maybe. So I was just sort of curious if people could sort of talk about
the anxieties and worries that you have. Dr. Berwick very nicely mentioned that the real
transformation across the country probably has to happen community by community. How
are we going to make sure that happens and we don t get sort of bogged down with [inaudible]?
Male Speaker: Thank you. Now, that was an ending question. Richard Frank: Yeah. [laughter]
Let me set the ground rules. [laughter] I think everybody probably has a view on this
question, so why don t we start at the far end, come down this way, and nobody gets more
than a minute. Lillian Shirley: Data, data, data, and flexibility, flexibility. I mean,
that s what we need from the feds. We need to say, In our state, in our communities,
we can do what you want to do. You define the success. But don t tell us how to do it.
You know, don t tell us with rules and administrative overhead. But we promise you -- and this is
the deal, this is the risk --that we ll let you know if we re doing it and we ll be honest
about when we re falling short so that we can achieve what Don Berwick was taking about.
But we have to have that flexibility. Elizabeth Mitchell: Okay. ACOs are not about check lists.
It s going to be about meaningful leadership and change. So, let the communities do what
we re doing well. We are so busy with early adopters; it s very exciting. But we need
to tell the story. We need to share the learnings. We need to find a meaningful way to capture
the lessons learned and make sure, you know, Oregon knows about it, Duke, anyone who s
interested. And so I think that s a really key role that we have to keep in mind. Lloyd
Michener: Just very briefly, I d add that I think adaptation of innovation is part of
dissemination. If you don t let the sites change it, then it won t stick. Craig Jones:
I think -- I ve got to turn it around again and frame it in a positive way. [laughter]
s already happened. So, last September when Secretary Sebelius announced the Multi-payer
Demonstration, Advanced Primary Care Practice Demonstration, and that for the first time,
Medicare would join state-led efforts. That was the beginning, that was a sign of a very
fundamental change. And it was a sign of being willing to take number -- we don t know how
many it s going to be -- partners and Medicare is going to join them in state-led efforts.
And I think as we ve watched the leadership of all of them over the last few months around
this within Health and Human Services and CMS, you re seeing the move toward that looking
at this department, these agencies as innovation centers as opposed to drivers of, frankly,
research environments, like they used to be. So I think we re seeing a change. Noel Clark:
You know, the traditional fee-for-service plan doesn t address, doesn t give communities
the flexibility that we need to deliver the results that payers are trying to buy. In
New Mexico -- I don t know if it s like this all over the country -- you ve got the Behavioral
Health Services Division that funds mental health services for under-insured and people
with no insurance. And their rules and their guidelines and their mission is not congruent
with Medicaid. And I think Medicaid [unintelligible] when they re looking at the F-map [spelled
phonetically] and they re looking at substance abuse [unintelligible] grants, they need to
assert a little more -- I can t believe I m saying this -- we need to be aligned. What
the state departments, what the state are doing with the state general fund need to
be aligned with what s happening, I think, with federal dollars. And I think also we
ve got to advocate for innovative payment systems for providers; fee-for-service isn
t going to work. We need capitation or allow us to assume some risk and put some financial
benefit out there if we achieve the outcomes that you re trying to buy. Andrew Allison:
I would point to the need for large, open-ended opportunities from the federal government
that match the scale of the problems, match the scope of the problem across programs and
would [unintelligible] in despairing the up-front risk for these initiatives given that really
that s where the benefit, most of it, is going to accrue. Secondly, I m a skeptic, I guess,
in the crowd and I think sometimes we fail and not all these initiatives are going to
save money, which is going to be key. So I think we need to help states know what works
and make sure that we help states repeat successes and not failures. On that point, hopefully
we ll do [unintelligible] as an ACA-related initiative that can help states do that. gd;[
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