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CMS Officials Aim to Foster 'Rising Tide of Innovation Mojo'

By John Reichard, CQ HealthBeat Editor

January 26, 2012 -- "Summit" meetings are supposed to be filled with a sense of high purpose and high energy. A gathering on the critical importance of health system innovation did not disappoint on either count.

The meeting built on one of the big themes in health policy in recent years—the idea that improving the quality of care is, happily, also the best way to address the national crisis of rising health spending.

Skeptics might dismiss that as fanciful thinking. But it's an article of faith among a number of health policy leaders. Among them are those involved in implementing the health law (PL 111-148, PL 111-152). Former Centers for Medicare and Medicaid Services (CMS) Administrator Donald M. Berwick championed the idea. And the Center for Medicare and Medicaid Innovation Center created under the overhaul is a hot bed of such thinking. Its leaders say there are plenty of real world examples in local communities around the country of how higher quality lowers costs. They say scaling them up nationally would begin to bend down the upward curve in health care spending. Now Berwick's successor, acting CMS Administrator Marilyn Tavenner, is aiming to fan the flames of such innovative thinking.

"Together we are creating a community of innovators, a chance for independent thinkers to meet and hear from others like them," Tavenner said in launching the "Care Innovations Summit" last week.

Through a website, 74 new "innovation advisers" from health systems around the country, and the summit, "We are not only sharing ideas. We're sharing the excitement that comes from creating such ideas," she said.

Surgeon, writer and former Clinton health aide, Atul Gawande set the tone for the event by saying that retooling health care is an absolute must within the next decade. Medicine is facing "the greatest crisis of its existence—and that's cost."

Doctors, he said, are being forced by events to consider costs in treating patients when until recently they had not done so.

"And then you look into our situation with the debt and the deficit and what you realize is that health care is destroying American prosperity. We are destroying the American dream. So what it means thinking about what I do day to day as a surgeon has become immensely more complicated."

Care More Complex Now

Hassles with bureaucracy and insurers complicate the job. But they are only symptoms of the deeper problem, which is the complexity of delivering care, he said. In the past two generations, "we have discovered 13,600 diagnoses—13,600 ways the human body can fail. We have identified 4,000 medical and surgical procedures, 6,000 medications that I am licensed to prescribe. And our job is to deploy that capability town by town to every person alive. There is not an industry that has to deliver 13,600 service lines in every community to everybody. Is it any surprise that we're finding it hard? The complexity is transformational."

The health system was built for a simpler time, he added. In 1970, just over two clinicians—basically a doctor and a nurse—were needed to care for a patient admitted to the hospital. By 2000, "the number of clinicians involved in the care of a patient admitted for a typical problem to the hospital was more than 15."

The system "was built at a time where what you wanted was autonomy and the individual judgment of that lone doctor. But when you have 15 people who have as their highest value autonomy—no communication, no way they knitted together, it breaks down. We've trained, hired, and rewarded people to be cowboys. But what we want are pit crews for patients. And we've not been able to get there.

"We know that it doesn't work and there are obvious signs. Forty percent of our coronary artery disease patients receive incomplete or inappropriate care. Sixty percent of our asthma, stroke, pneumonia patients receive incomplete or inappropriate care. And if you have severe mental illness the problem is even worse."

Doctors, he said, want to say that this is what medicine costs; that arthritis in the knee that once was treated with aspirin is now treated with $15,000 for a knee replacement. But the reality is that there is a wide gap between what the most expensive and the least expensive places are "for the same patient, the same problem.

"If what you needed was to get the most expensive care then we really would be having a rationing discussion. The only choices would be who gets it. But what turns out is that the places getting the best results are not the most expensive places in the country for care. In fact many of them are among the least expensive. And that means there's hope. We need to learn what the positive deviants are doing.

"What we're beginning to see in the lessons is that the most successful behave like systems. That is they somehow make the different components of care —all those specialists, all those drugs, all those devices—fit together somehow."

New Skills Needed

Certain skills must be cultivated. "First is how to tell the difference between success and failure. And the key to that is data," he said. "We need some deep thinking about whether what we need are broad systems that let us see lots of different things along the way. Or some of the most powerful sources of data have come from really registries that are very specific to different problems; registries that look at our cardiac patients, our cystic fibrosis patients, and collect deep information to guide and see how well the care has really gone."

Another skill is to diagnose which types of patients cost the most and pinpoint what about their care drives up costs, Gawande said. The list of such patients includes ischemic heart disease, heart failure, diabetes, chronic kidney disease, and chronic obstructive pulmonary disorder. That helps determine priorities where the most focus is needed.

He said for example that "we have not dug in far enough to know, well, what is most expensive about ischemic heart disease. We have to dig in and understand."

Even once the problem areas are understood, doctors aren't good at figuring out how to deal with them, Gawande added. He said that he, for example, is part of a World Health Organization initiative to reduce surgical deaths. He and his colleagues did not know how to tackle the problem and sought answers in other "high-risk, high-failure" fields such as aviation and building skyscrapers. Like medicine, those fields employ lots of training and lots of technology but they differ in that they rely on check lists.

"Now it's not that check lists are the thing. It's that it's the simplest form of organization to get teams together to think about what great care or great performance looks like and then have a few basic components that are designed to make it so you can do it. We in medicine underestimate the value of careful design, design about how you achieve great care. Restaurants think incredibly hard about how you accomplish it."

The WHO initiative brought in a Boeing engineer to design a check list of the kind pilots use in the cockpit—but for health care teams doing surgery. Items range from making sure it's the right patient to having each member of the team introduce themselves to each other and making sure they've briefed each other on the goals of the operation, how long it will take, the key medical issues and the equipment involved. Using the check list in eight cities in the U.S. and abroad lowered surgical complications by 35 percent and the deaths by 47 percent at the hospitals involved," Gawande said. "And it's free."

On average every complication eliminated saved $14,000.

"The VA system has since adopted it with an 18 percent reduction in deaths. And yet we are still barely penetrated in operating rooms in the United States."

In his talk, Gawande emphasized that it would not cost a lot to make the changes necessary to dramatically bring down health costs.
Retooling health care into a more systematic team based approach "is a battle for the soul of American medicine," he said. "What are here for? What are we trying to do? It is the fundamental issue of this century. Making it possible for people to survive and live the lives they can live with all of the science and knowledge we've discovered and bring it across an entire society."

Just as America in the last century mastered the challenge of economically meeting another human need—food—so too must it find the way to do the same for health care, Gawande said.

Other Ideas

Other speakers at the forum likewise championed the idea that improved care would lower costs. "Sometimes we wonder in health care is it really possible?" said Richard Gilfillan, the head of the innovation center. He too emphasized the need for better data to identify ways to improve care and lower costs. And once those ways are identified, he added, the center is a powerful force for fostering change because it can issue regulations nationally in Medicare for example to pay primary care doctors an extra sum per patient per month to coordinate care if that's found to improve medical outcomes.

At times the meeting seemed akin to a political rally of boisterous young idealists firing themselves up to undertake a long reform campaign. The chief technology officer at HHS, Todd Park, punctuated his remarks with exuberant fist pumps in calling for the greater use of data to foster a retooling of care. "The reinvention of American medicine driven by a rising tide of innovation mojo has already begun!" he shouted in concluding his presentation.

As much energy and enthusiasm as was evident at the event, the future of the Innovation Center is uncertain. Congressional Republicans, skeptical that government can drive innovation from the top down, have questioned whether it is worth the $10 billion budget it has received under the health law.

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