Multilevel Interventions in Health Care Conference: Presentation by Kelly Devers, PhD

Uploaded by NIHOD on 05.05.2011

>>>DR. STEPHEN TAPLIN: Now it's my pleasure to introduce
Kelly Devers. Kelly is a senior Fellow in the
Health Policy Center at the Urban Institute
in Washington, D.C. Dr. Devers' current research
focuses on the implementation of national and state health
policy reforms. And that's kept her very busy.
She's particularly related to patient centered medical homes,
accountable care organizations, and related provider payment
changes. Hospitals and medical groups efforts to improve
quality and efficiency through the use of electronic medical
records and process redesign techniques,
and efforts to improve the quality of cancer care in
community hospital based cancer centers. That's a lot.
She does a lot and we're glad to have her here.
She earned her Ph.D. from Northwestern University and
I think she's very much in touch with what's going on with
health care reform, and through the Urban Institute and
through the activities that are going on in Washington, D.C.
So we look forward to hearing from her and having her
contributions incorporated into the journal. Away we go.
>>>Kelly Devers: Thank you so much for the introduction
and it's really a pleasure to be here. I rarely,
after hearing about evaluations I'll do my best to keep us on
time and keep you entertained this morning. I want to take a
minute to acknowledge my co-conspirators in this paper.
Dr. Baronson who is at the Urban Institute with me,
Mary Fennell and Ann Flood. But I take all accountability for
any flaws in the talk today. Our purpose was really to try
to identify, describe and discuss some key provisions of
the Affordable Care Act and the federal stimulus bill known as
the American Recovery and Reinvestment Act. In particular
I want to focus on new care delivery models,
new provider payment models that often are accompanying
those changes in delivery, and health information technology.
I want to highlight and try to draw out their impact on cancer
care and implications for research. I don't want to keep
you in suspense so I'm going to hit my major themes and
takeaways right now. First of all,
I think we all as Arnie alluded to and said,
big changes are underway with the historic passage of the
Accountable Care Act. And as Dick Scott reminded us,
that's not going to sort of, that didn't happen the day
President Obama signed that piece of legislation. We are in
the early, early phases of the implementation of that historic
piece of legislation. The political and economic and
other legal realities of the legislation are continuing to
be debated at many levels and will continue to play an
important role in how that bill is eventually implemented but
over the next decade or so. So we are at the very early
stages, but we do anticipate big changes. It won't be
business as usual. It will be influencing multiple levels of
our health system and in fundamental areas. As some of
you might know, the Accountable Care Act really focused on two
fundamental areas, coverage and coverage decisions. And then
the organizational delivery of care. But what I mean by
coverages, who will have access to health insurance,
what kind of insurance company is going to cover them. And in
terms of coverage decisions, things like what technologies
and services are going to be paid for and how,
comparative effectiveness and other kinds of techniques are
going to play into those coverage decisions moving
ahead. The second major component of the legislation
focused on the organization and delivery of care and the
related provider payment changes. And that's really what
I'm going to focus on today. But I do want to point out that
those major changes in coverage will impact the organization
and delivery of care also in terms of the fact that we
potentially have 30 million more Americans covered under
insurance. And there will be tremendous pressure on access
as well as keeping costs under control,
as well as keeping quality up, or maintaining or improving
quality. So that brings me to my second point. Basically the
changes underway will impact cancer care in significant and
highly unpredictable ways. We are in an incredibly dynamic
period. The health system is particularly complex and
dynamic, and we can pretty much expect unintended responses and
consequences. These times and changes require big science,
and I'm sort of, stick with me here. I want to take a minute
to say what I mean by big science. I think the most
concrete example of big science that we have is the human
genome project in health care. That was started in the 90's
and really represents a historic and major investment
by the government in scientific research to sequence the human
genome. We have had big science, that term was coined
right after World War II, where the government got
involved in significant way in basic research.
And in a historically unprecedented way,
the government was playing a major role to develop the
infrastructure for scientific research,
including investment in major pieces of equipment,
laboratories, training, all the like. So our current example in
our health world is the human genome project. And what we're
calling for is certainly not big science of the magnitude of
the human genome project, but thinking in terms of both
mentality and the infrastructure necessary to do
large scale projects in terms of the organizational delivery
of cancer care and its impact on outcomes for patients.
So with that said I want to give you some concrete examples of
some changes underway in the delivery system and what it
means for cancer care. First of all, what is a patient
centered medical home? Well, some would say it's a really
good primary care practice plus, and we have some experts
here, Kurt Stange and others who are doing great work
in this area. And the purpose is to support and improve
primary care, particularly access, patient centers,
care coordination and management. There are literally
dozens of specific patients in a medical home definitions out
there and numerous assessment instruments. But they share
seven common principles. Personal relationships,
whole person orientation, team delivery of care,
care coordination across specialties,
care settings and time, quality and safety improvement,
enhanced access, and adequate and/or new payment models to
support these changes. We have a lot of activity underway with
patient centered medical homes. Recently CMS announced its
support for the advanced primary care demonstrations,
and I know that work is underway to get that off
the ground. In these demonstrations,
Medicare will be joining multi-payer medical home
efforts in eight states around the country. We also have multi
stakeholder pilots of medical homes underway already in 18
states, and there are currently 39 Medicaid associated patient
centered medical homes. Some are exclusively Medicaid or
CHIP for kids, and others are parts of multi-payer efforts
with commercial health plans. What is the potential impact
on cancer care? Well, one question is,
are primary care providers well suited to serve as the medical
home for cancer patients and to coordinate the cancer care for
their particular patients that might have cancer. The second
question is, can oncology practices and oncologists be a
medical home. There is a vigorous debate right now in
the literature about whether specialties,
different kinds of specialties including oncologists,
could serve as a medical home. Aside from that question,
how do we encourage and support positive aspects of medical
homes in oncology practices, regardless of what we call
them, how we pay them. Things we want to encourage like
patient (inaud.), shared decision making,
care, integration and coordination,
how can we encourage that in oncology practices or on
multiple different types of oncology practices that are
typically involved in a single patient's care. And how might
medical homes effect multi-disciplinary care in
cancer teams. A second major delivery system model underway
is called an accountable care organization. And again,
I ask you to bear with me because this is an abstract
concept, although I'm sure all of you have seem some version
of an accountable care organization in your area.
But there are some significant or notable changes to what you
might already be familiar with. And one simple way I say this
is, some people ask me, is it an accountable care
organization an HMO in drag? Or isn't it an integrated
delivery system, or is it a this. And I say,
well it can be all of those things,
but there are some important differences. I'm going to try
to be clear about what the differences are. Okay.
An accountable care organization attempts to couple provider
payment and delivery system reforms together. It attempts
to solve a chicken and egg problem by,
in the sense that people will say,
well we can't change our delivery system because we
haven't changed our payment models. And people in the
payment model side say, we can't change our payment system
because there are no provider organizations able to accept
the kinds of payments we would like to give to them.
Like different kinds of risk adjusted payments,
bundled payments, other things that would require the
organization to take some accountability for a broader
spectrum of care and manage the care and the dollars.
So we have this conundrum. The ACO attempts to couple those
things together. Another critical feature is that an
accountable care organization is a form of direct contracting
between Medicare or purchasers, and providers,
cutting out Medicare plans. As you might have seen in the
health care reform debate, plans were not seen as the
heroes of the future. We feel like we've gotten very little
in some ways for our money from health plans. There are some
good ones like the Kaiser Permanente's,
but there were a lot of ones that we couldn't quite see the
value. The purpose here is to say,
Medicare contract directly with the set of providers.
You providers help manage the dollars and the quality of care
(inaud.) help manage the risk. So it goes directly to
providers. ACO's are purposely designed to be flexible.
People say, we don't know what the right delivery system model
is, let's experiment, let's let flowers bloom or things related
to regional areas come up from the ground. So we understand
that there's a lot of variation in local markets,
and we need to experiment, we need to build on that variation
cross market in terms of provider organization's
capacity and willingness to accept non-fee for service
payments. And we need to experiment with new payment
methods. An accountable care organization then is only
broadly defined as a group of providers specifically,
or at least including, primary care,
specialists and hospitals that can be jointly held together,
held accountable for the quality and cost of care.
So they at least have to have a legal umbrella and a legal
infrastructure that says we're working together and are going
to accept responsibility for these 10,000
Medicare beneficiaries. They don't have to be owned by the
same organization, they can stay in all kinds of different
configurations. So this picture, or this figure really is
just designed to give you a quick sense of two things.
One, there are very different models of who
might lead an accountable care organization.
Everything from a set of primary care physician groups
who then will go out and get the specialist thingy,
or decide what hospital they're going to contract with.
To something that we've seen before in organized delivery
systems that owns and operates already all of these pieces.
Up in the blue box is tertiary or quaternary care,
and this is important because we recognize that in certain
areas of the country patients are still going to want to go
to academic medical centers or other kinds of centers out of
the area or out of their accountable care organization
network. We want patients to have the freedom to do that.
But if the accountable care organization has a strong
incentive to keep total costs in check,
and they have quality metrics, they may want to keep those
patients inside their own accountable care organization
network. So it has the potential to change referral
patterns to academic medical centers and NCI designated
centers, etc. So, the first step of ACO pilot is well
underway, and we expect the 800 page rule to be out in the
next month. So there will be plenty to look at in terms of
the details of this program. And there is significant interest
in this pilot by providers as well as public and private
purchasers. I think I've already alluded to the impacts
on cancer care. These sets of providers will have a greater
incentive to reduce total cost of care. The strength of the
incentive will vary by the specific models,
payment models allowed under the pilot. And they alter
referral patterns. There will be more incentive to meet
quality targets and hence a greater need for an emphasis on
risk adjustment and quality measures to protect against
stinting on care. We really want to try to understand to
what extent will academic medical centers or NCI
designated cancer centers be able to lead or participate in
an ACO, and learn how the hospice,
nursing homes or other kinds of services fit in here.
As you might imagine, any change in payment,
like episode based payments for cancer care,
leads to debate. Significant debate. That's all I need to
say about that. EHR's. Most of you know what electronic health
record is. The largest investment by the federal
government through our High Tech Act,
approximately $30 billion, to facilitate,
adapt and upgrade, and meaningful use. There's a lot
of detail in what we mean by meaningful use,
but it's essential evidence. Things that the government
feels is evidence based uses of an electronic health record
that will lead to quality and efficiency gains. So you can't
just buy an EHR and stick it on your,
put in your office and not use it in these ways. And there's a
variety of ways the government will be monitoring the use to
make sure providers are getting payments to use it
appropriately. Electronic health record,
as you might see from the diagrams,
isn't very good if I can only have it in my office and I
can't exchange data with the hospital or specialist.
So health information exchange and building that information
highway is critical and also underway. We ultimately hope to
increase quality and efficiency in patient centered care in a
secure environment. But as you know it's highly complicated,
so many oncology practices are underway trying to make this
complex technology work in their practice. And it may have
disruptive and unintended effects. Health information
exchange provides new opportunities to share
information among oncologists, hospitals and researchers.
But also there's many technical challenges and concerns about
privacy, security, and related legal matters. Punch line.
Implications for research, basically what are the impacts
of patient centered medical homes,
ACO's, and health information on integration,
care coordination across the continuum in these key
outcomes. In our patient centered medical homes and
accountable care organizations, complementary or conflicting.
And how do EHR's and HIE fit into the patient centered
medical home in ACO's. A lot of the assessment tools for the
patient centered medical homes, for example,
require electronic health record capacity. In some,
in terms of our topic, in terms of multi-level research,
I think, I hope I've given you some sense that these are,
these major delivery system and payment reforms underway are
very complex. They will play out differently across the
country. They're multi-component and they're
multi-level. Federal, state, local, region, market, down
to hospitals, practices, down to the patient level.
Now methods must match the times and our current
multi-component, multi-level research toolkit has some areas
of strength and progress, but also some serious gaps.
And I would argue we need big science, we need
a comprehensive approach. Work in one area methods
or data, or some of these areas alone won't do
it. We need larger scale projects and larger investments
to bring teams of researchers and perhaps centers together in
a broad scale approach to meet the needs of the field of
researchers and diverse policy makers,
payers and providers. As well, of course,
patients and local communities. Thank you.
>>>DR. STEPHEN TAPLIN: Thank you, Kelly. I think it makes
it clear that we have a future, there is a future set of
questions, and a future world which is going to be quite
different than what we're used to. And I think that's an
important motivation for thinking about what we're
doing and how we're doing it, and how we move forward.
So I think that's a critical background and I'm glad
to now have it incorporated into the meeting.