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Weekend Shifts Broaden Perspective of CMS Top Doctor

By Kerry Young, CQ Roll Call

May 28, 2015 -- Hospitals may be saving as much as $459 million a year partly because a doctor on a weekend shift once too often witnessed a nutritionist having to dictate orders to a busy resident instead of handling them directly. In his weekday job as a top Centers for Medicare and Medicaid Services (CMS) official, Patrick Conway was well positioned to change the federal rule that blocked hospitals' nutrition experts from entering the information on their own.

"One of the things that triggered that is that I was watching for about the 100th time a dietitian tell the resident what to enter into the computer because only the resident, who is a physician, could enter diet orders," said Conway, CMS' chief medical officer, in a recent interview.

Conway, who also leads major quality-improvement and innovation initiatives within CMS, cited this as an example of how his decision to continue practicing medicine influences his work on health policy. A pediatrician, Conway said he works weekend shifts at Children's National Medical Center in Washington, D.C., about once every six weeks. That clearly takes some schedule juggling, as Conway also is the married father of three young children. But he said the weekend hospital shifts recharge him and he described the practice of medicine as "a calling."

"It keeps me connected in a very important way," Conway said. "It informs everything from payment policy to clinical standards."

Nutritionists had pressed for several years for a change in hospital rules, which CMS has great sway over nationwide through the conditions that the agency sets for coverage and participation in its programs. With Conway's help, the agency last year finalized a rule that makes it clear that dietitians can enter orders directly. The change could save as much as $291 million a year in labor-related costs, plus another $168 million from an expected reduction in the cases of inappropriate use of nutrition given by tube, CMS estimated in the final rule. The Academy of Nutrition and Dietetics, which represents about 75,000 registered dietitian nutritionists and other professionals in the field, greeted the new rule as a "major policy success."

"You're enabling people to practice to the top of their license," Conway said of the change.

The weekend hospital shifts give Conway a first-hand look at the medical profession in the midst of what he described as "a long-term transformation." CMS is a key driver of these changes, which include greater use of electronic health records and other steps that have caused grumbling among medical professionals. By continuing his own hospital work, Conway can relate more easily to colleagues facing pressures and inconvenience associated with these changes.

"I actually use the electronic health record in care delivery," Conway said. "There's a credibility factor. If you are still practicing, I think it helps you to communicate in a more credible way with physicians."

Conway is also clearly comfortable on the wonkier side of medicine. After graduating from Baylor College of Medicine, he earned a graduate degree focused on health services research at the University of Pennsylvania. He's listed along with CMS' chief data officer Niall Brennan as one of the highlighted speakers for Health Datapalooza 2015, a major conference that starts May 31.

At CMS, Conway said he finds his days often filled with "a lot of meetings." To try to improve efficiency within his parts of the agency, Conway is borrowing the "lean" method pioneered by automaker Toyota, with a focus on improving the effectiveness of processes and eliminating waste. For the clinical standards and quality unit that he oversees, this has dropped the contract modification time by 50 percent from 8 weeks to 4 weeks. In the Center for Medicare and Medicaid Innovation that Conway oversees at CMS, the time for providing technical assistance to participants in certain pilot programs fell by approximately 4.5 months, according to Conway.

The $10 billion innovation center was created by the Affordable Care Act, and Republicans have questioned its effectiveness. In his work, Conway seems to seek to stay out of the continuing conflicts about the law. He spends his time instead searching for better ways to deliver health care, said Mark McClellan, who led CMS during the Bush administration.

"He is really good about trying to reach out to a wide range of different perspectives, trying to do what's what right for patients and for the program and not focus on any partisan or political issues, but really try to make Medicare a stronger program for the future," said McClellan, now a scholar at the Brookings Institution and a member of the board of directors of health giant Johnson & Johnson.

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