Tuesday, January 4, 2011

Innovations in Healthcare Delivery

In the next 20 years, more of the federal budget will be devoted to Medicare and Medicaid, according to Richard Gilfillan M.D., Acting Director of the new CMS Center for Medicare and Medicaid Innovation (CMMI). As the keynote speaker at the Health Affairs day-long Conference “Innovations Across the Nation in Health Care Delivery” held on December 16, 2010, he described how important it is for reforms to be in place to meet the challenges facing the 21st century healthcare delivery system.

Congress provided CMMI with funding of $10 billion for fiscal years 2011 to 2019. The goal is to transform and transition from a claims payer supporting fragmented care system to seamless coordinated care by developing Accountable Care Organizations (ACO) and community population health models. The law also gives the HHS Secretary authority to expand the duration and scope of models that improve quality and reduce costs.

Dr. Gilfillan wants to hear ideas from hospitals, doctors, consumers, payers, states, employers, advocates, relevant federal agencies, and other stakeholders to obtain input and build partnerships. In his travels around the country, he talked to a group of young doctors at San Francisco General to hear ideas on how the primary care field can become sustainable so that young doctors will go into the field.

As Dr. Gilfillan explained, CMMI is going to test models establishing “open innovation communities” to serve as information clearinghouses for the best practices needed to deliver healthcare. These communities will be testing grounds for new practices and foster the ongoing exchange of ideas on how to meet the shared challenges.

Several recent CMS innovative initiatives:

• The Multi-Payer Advanced Primary Care Practice Demonstration is expanding to eight states to participate and will establish medical homes to serve one million Medicare beneficiaries. The demonstration will evaluate how effective it is for doctors and other health professionals to work in a more integrated fashion

• The Federally Qualified Health Center Advanced Primary Care Practice Demonstration will look at the effectiveness of doctors and other health professionals working in teams to treat low-income patients at community health centers. The demonstration will be conducted by the CMMI Innovation Center in up to 500 FQHC’s and provide patient-centered, coordinated care to 195,000 Medicare beneficiaries

• The launch of the Medicaid Health Home State Plan Option enables patients enrolled in Medicaid with at least two chronic conditions to designate a provider as a health home to help coordinate treatments

• The Innovation Center recently announced the availability of contracts for the states to design innovative methods for delivery and payment models for dual eligible individuals. The plan is to award contracts up to 15 states of up to $1 million each. The solicitation package is available now with applications due by February 1, 2011

Another presenter, Lee Sacks M.D., Executive Vice President and Chief Medical Officer of Advocate Health Care and Chief Executive Officer of Advocate Physician Partners, pointed out that it is unclear exactly how these ACOs as part of Medicare will be structured.

Dr. Sacks reports that his organization Advocate Physician Partners can serve as a model for a new kind of ACO that organizes physicians into partnerships with hospitals to improve care and cut costs.

As he explained, there are at least four immediate challenges in starting ACOs. The facts are that generally solo and small group independent physician practices are dominant, voluntary medical staff structure exists within most hospitals, and dominance of fee-for-service reimbursement still exists. It is also important to spur ACOs in the private commercial market and not just confine ACOs to programs such as Medicare and Medicaid.

He explained how his Partnership thinks CMMI can help. In order to help establish ACOs, he suggests that Medicare claims should be available in real time, data be provided on patients when out of network, incentives aligned so clinical integration expands to Medicare fee-for-services, and expand the ACO infrastructure. For the first time, his Partnership has signed their first commercial ACO contract which became effective January 1, 2011 with the largest insurer in Illinois, Blue Cross Blue Shield.

An article authored by Mark C. Shields, Pankaj H. Patel. Martin Manning and Lee Sacks appears in the January 2011 Health Affairs issue, entitled “A Model for Integrating Independent Physicians into Accountable Care Organizations”. The article discusses in detail how Advocate Physician Partners with 3,500 physicians can work to develop the ACO model.

For more information on CMMI, go to http://innovations.cms.gov.