The Sweet Spot Between 'Rigor' and 'Rigor Mortis': Balancing the Need for Evidence-Based Innovations and Rapid-Cycle Change
Recognizing the need to identify, develop, and disseminate new approaches to health care delivery that can both improve the quality of care and lower costs, Congress created the Center for Medicare and Medicaid Innovation as part of the Affordable Care Act. Ten billion dollars in funding was allocated to support the Innovation Center’s goals from 2011 to 2019.
The Innovation Center is tasked with testing innovative payment and service delivery models to reduce program expenditures while enhancing or preserving the quality of care in Medicare, Medicaid, and the Children’s Health Insurance Program, with a particular emphasis on care coordination and patient-centered models. While models tested do not have to be cost-neutral from the outset, they must show that they are improving quality without increasing costs, or reducing costs without negatively impacting the quality of care over time.
Principles guiding the Innovation Center’s work are:
- Test new models of care and implement those shown to improve quality and decrease costs in the Medicare and Medicaid programs, providing a signal to private payers;
- Keep the patient and family perspective front and center when determining success;
- Strike a balance between national action and coordination with local innovation and implementation;
- Align federal efforts with states and private payers to deliver better care; and
- Balance urgency with the need for the testing and evaluation of innovations to determine what works.
On Monday, July 18, more than 350 congressional and administration staff, journalists, and other Washington, D.C., policy stakeholders convened for a briefing on the key issues facing the Innovation Center, including the need to balance the testing of innovative ideas with rapid-cycle deployment of new ideas and ways to deliver care. Jointly sponsored by The Commonwealth Fund and the Alliance for Health Reform, the briefing featured Marsha Gold of Mathematica Policy Research, Inc., who addressed evaluation; Paul Wallace of the Lewin Group, who discussed the importance of the patient perspective; and Tim Ferris, M.D., of the Massachusetts General Physicians Organization and Harvard Medical School, who looked at the health care provider's role in identifying and rolling out innovative practices. The panel concluded with Peter Lee of the Center for Medicare and Medicaid Innovation, who discussed the Center’s guiding principles, infrastructure, and early initiatives. The briefing was comoderated by Ed Howard of the Alliance for Health Reform and Stuart Guterman of The Commonwealth Fund.
Marsha Gold explained that in terms of evaluation, what the Innovation Center is taking on is a departure from the historical model. Under the traditional model, a target population is carefully defined, comparison groups are composed to serve as a benchmark, metrics are constructed from centralized data files, and the process is long enough to distinguish short-term effects from stable long-term effects. In contrast, the innovations tested by the Innovation Center are likely to consist of “national” demonstrations across widely divergent organizations, with many locations testing the innovations in their own ways. This is essential to allow for “from the ground-up” innovation and local flexibility but could pose measurement challenges, such as determining what the shared metrics should be. Gold also pointed out that it will be essential to facilitate timely measurement and feedback to innovators on metrics that matter to them. Gold stressed the importance of having realistic expectations and remembering that implementation of even the best, evidence-supported ideas often takes longer than is expected and that momentum, especially among providers looking to test or adopt innovations, is critical: waiting for the perfect information is less important than getting started and including mechanisms for midcourse corrections if needed.
Paul Wallace explained that for effective learning and spread to take place, the dialogue needs to happen at the national policy level (what works?), the state, systems, and practices level (what works here?), and the patient/provider level (how does this impact me?). He reminded the audience that although the level of rigor and demand for evidence is rightfully high at the national policy level, no system, provider, or patient has the luxury of waiting for perfect information before they act. Decisions are made every day with very little evidence and we need to strike a balance between striving for evidence-based innovations and holding out for the idealized level of certainty that may never present itself. He pointed out that the majority of innovations tested will fall into the gray area, with neither definitive evidence that they are ineffective nor that they will be successful for all patients. How the Innovation Center operates within the gray area will be key to its success.
As medical director of the Massachusetts General Physicians Organization, Tim Ferris underscored that uncertainty can stifle innovation within a health care facility. He discussed the “engaged doctor’s dilemma”: how to know in which direction to move when faced with uncertainty around policies related to payment and delivery system reform. Ferris outlined three clear directional indicators for leaders at Massachusetts General Hospital (MGH) regardless of the policy context: 1) change focus from units of care to episodes of care and population-level outcomes; 2) move forward with the things that have been shown to improve outcomes and/or reduce cost; and 3) always improve, creating an incentive structure that rewards continuous innovation. Ferris explained that it’s important to remember that innovations need not be brand new ideas but can also be lessons on how to implement an existing approach in a new setting. An example of this is the MGH Care Management for High Cost Medicare Beneficiaries demonstration, in which a care manager was provided to high-risk primary care patients. Results from an independent evaluator showed that implementing this innovation resulted in a 7.1 percent annual net savings for enrolled patients and showed that for every $1 spent, the program saved at least $2.65. Ferris closed by reminding the audience that changing the way we deliver and pay for care will take time and that we need to be patient, allowing providers the flexibility they need to innovate in ways that make sense for their settings and possibly lowering regulatory requirements for engaged providers.
Peter Lee reiterated the belief that underlies thinking at the Innovation Center: innovation is not restricted to ideas formulated in Washington, D.C., but is happening in virtually every community across the country. The Innovation Center is positioning itself to partner with states, communities, organizations, and providers in testing new innovations. It will be looking at recommendations from the Medicare Payment Advisory Commission (MedPAC), the Medicaid and CHIP Payment and Access Commission (MACPAC), the Institute of Medicine, and private efforts such as The Commonwealth Fund’s Commission on a High Performance Health System, to identify models to test and potentially disseminate. Lee described the Innovation Center’s four initial priorities:
- the reinforcement and support of primary care through Medicare and Medicaid patient-centered medical home models and other initiatives;
- multipayer initiatives like the Multi-Payer Advanced Primary Care Practice Demonstration, in which Medicare and Medicaid are partnering with private payers to develop new approaches to care;
- coordination of care models and new approaches to payment through the Pioneer Accountable Care Organization program, as well as by aiding in the adoption of models proven to reduce hospital
- acquired infections and avoidable rehospitalizations through the Partnership for Patients project; and
- integration of care for beneficiaries who are dually eligible for Medicare and Medicaid both across the two programs and multiple care settings.
All of these efforts recognize the need for rapid-cycle development and ongoing support, midcourse corrections or discontinuation when necessary, and scaling up when results show promise for improved care and reduced costs, Lee said.
Overall, the briefing emphasized that moving from a health care system that rewards value of care delivered instead of volume of services provided is a laudable goal that resonates with policymakers and providers alike, regardless of political persuasion. The economic reality facing our country makes it even more critical to identify models of care delivery and payment that move us toward this goal. The key will be to allow for enough flexibility to try new models of care while understanding that not all will succeed. If we don’t try, we will undoubtedly fail in changing either the way care is delivered or how it’s paid for.
In the words of F.D.R., “The country needs, and unless I mistake its temper, the country demands, bold, persistent experimentation. It is common sense to take a method and try it. If it fails, admit it frankly and try another. But above all, try something.”