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Delivery System Day: Chris Jennings

Chris Jennings served as a senior health care adviser to the White House from 1993 to 2000. He wasn't quite a czar, but close. And so he is particularly sensitive to the political structuring of some of this stuff.

You will hear ad nauseam about Accountable Care Organizations (ACOs) and Comparative Effectiveness Research (CER) and their respective interaction with a modernized infrastructure (helped to be created by HIT). All are important and should be highlighted, but I figure you will get this from multiple sources.

Instead, I choose to focus on a couple of other diamonds in the rough. The first would be the funding for prioritization and development of quality measures linked to aggressive reimbursement incentives to physicians for reporting on these measures. (These measures, developed by health professionals, are used to promote best practices for some of the most expensive chronic diseases, such as heart disease, cancer and diabetes). I have concluded that we will never really change the way we deliver health care without the buy-in of the medical profession, which can only be secured if they develop and apply measures that can be used to empower practitioners and hold them accountable through comparative outcomes with/by their peers.

A second, and related issue, is a Finance Committee provision which gives CMS the authority to develop pilot programs to test methods of reimbursing providers for chronic disease management, (including collaborations with the states and the dual eligible program). Today, the easiest course of medical intervention is to prescribe treatment plans that deal with the effects of the disease, high cholesterol, high blood pressure, etc., rather than spending time with patients to help motivate them to take control of their health and manage their own diseases through lifestyle changes. Only when patients begin to understand that they must be the focal point of any intervention to constrain or even reverse the course of expensive chronic illness and, ultimately, produce savings, will we have made progress. The most creative part of this policy is to allow the pilots to be constructed in a fashion that waive strict budget neutrality requirements (because this has killed ideas in the past) AND allows them to expand nationally automatically (without any other legislative action) IF they can prove budget neutrality or better in the budget window. We all know that chronic illness is the primary contributor to our nation’s health-care tab – preventing and managing it is one of the absolute keys in getting the ultimate job done.

That last bit on automatic expansion is something I hadn't heard before. But it makes a lot of sense.

By Ezra Klein  |  September 22, 2009; 3:42 PM ET
Categories:  Health Reform  
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Comments

A question I have about comparative effectiveness research is "what constitutes an adequate period of time and a sufficient set of treatment alternatives to conduct an informative comparison of effectiveness?" That is, when does comparison stop and recommending or preferring begin?

Posted by: bdballard | September 22, 2009 4:01 PM | Report abuse

Ezra,

First off, I really like the idea of the delivery system pieces and credit to you for focusing on this aspect. This part of health reform will only really get off the ground once once a dialogue starts. So great contribution generally.

That said, the responses and so-called "experts" are too predictable. I'll make a couple of substantive points, but as a group, we've got a group of academics/think tank guys, with the only practical experience among the group being in DC/political experience-- none actually in the health care industry. Which for an issue that is as nuts and bolts like delivery system reform is a major problem. This isn't looking at macro-level trends on outcomes and financing and doing comparative systems analysis. This is about understanding what's been tried on cost control to date in the industry, why has it failed, and addressing those issues. This is the important point. At the end of the day, nothing-- NOTHING-- that has been mentioned by this group hasn't already been tried as possible solution. Chronic care management, accountable care organizations, comparative effectiveness, paying for quality-- all of these are known cost targets, with prior attempts having failed. Legislation that simply states that we should "experiment" and "pilot" rather than address challenges identified in prior experiences is a major flaw. Folks in the industry have actually been trying to solve these problems for a while. The known stumbling blocks are not things that are going be solved by pilot programs.

ACOs? Its the same thing as IHN's of the 90's. The lesson? Most physicians don't want to be accountable employees to a larger organization, they like being physician owners. They'll give up this autonomy if you buy them out at financial numbers that don't make sense. THAT's the issue.

Posted by: wisewon | September 22, 2009 5:30 PM | Report abuse

Pay for quality? As Berwick, Wennberg and others have noted, Medicare is woefully behind the private sector in using quality as a compensation metric. Jennings makes one of the best points here that physicians needs to be part of the quality-setting process, but there are plenty of existing consortia that are working with medical specialty societies to accomplish just that. The problem? Physicians don't actually want a significant portion of their compensation tied up in quality metrics. They like their current ability to get paid for doing whatever they want, regardless of the quality. Who wouldn't? THAT's the issue.

Comparative effectiveness? Sure, there's plenty more to learn (although as much more about CLINICAL effectiveness, rather than purely the comparative sort). But the reality is that we've got plenty of data to date on many things, comparatively speaking, but people simply don't want to be told no when it comes to health care utilization. So its a lot easier to say that we don't have perfect information-- as academics are apt to do-- rather than recognize that most data is based on global data sets, and the the Europeans have somehow figured out how to use today's "inadequate" data set to make the sorts of cost-saving comparisons/restrictions that our academics claim we can't do today. The problem? Politicians have exploited/demagogued insurance companies making them dishonest brokers on restraining health care utilization and constraining Medicare is a political death knell. People don't want to be told no, even on the many things, totaling billions in expenditures annually, that we know today are not value-based health care. THAT's the issue.

Posted by: wisewon | September 22, 2009 5:33 PM | Report abuse

Chronic care management? The private sector has been on this for a good twenty years. The are companies galore that have gone through dot-com like valuation fluctuations, based on their "new" models to coordinate chronic care. Medicare Advantage already provides disease management as a set of services that Medicare doesn't. The problem? To date, these services haven't been cost-savers, or even budget neutral. They still are good value-based medicine, but cost savings haven't been realized. There's nothing that folks could point to as a real reason why we should think differently this time. Improved coordination via ACOs/IHNs/staff model HMOs all would be great, but as I wrote above, there really isn't a clear way to make most of medicine practiced that way. THAT's the issue.

That covers most of the "promise" that the "experts" highlighted as reasons for being excited about delivery system reform. There's a reason that they guys in the trenches-- Cortese, Halvorson, etc.-- aren't impressed. There simply isn't one idea here-- with the MedPac proposal as the one potential exception (but even that is pretty defanged)-- that hasn't been tried already with the ultimate stumbling block being that physicians don't want to change behavior and/or patients don't want to make any compromises on care, no matter how cost-ineffective it may be. Those are the core issues that have been punted down the road, as they are not surprisingly political nightmares. But color me very unimpressed with the "excitement" being highlighted by a group of academics that haven't spent real time actually doing the business of delivering health care.

Posted by: wisewon | September 22, 2009 5:34 PM | Report abuse

--"Today, the easiest course of medical intervention is to prescribe treatment plans that deal with the effects of the disease, high cholesterol, high blood pressure, etc., rather than spending time with patients to help motivate them to take control of their health and manage their own diseases through lifestyle changes. Only when patients begin to understand that they must be the focal point of any intervention to constrain or even reverse the course of expensive chronic illness and, ultimately, produce savings, will we have made progress."--

How are you going to *make* patients "understand", Jennings? Are you going to threaten them, or just start taking their money from them until they begin to "understand" what it is that you think is best for them to understand? I mean, how else do you propose to "motivate them to take control of their health" with government edicts, other than by some force or another? C'mon, why don't you just outlaw McDonalds and Coca-Cola? That'll motivate people, won't it? They'll be sure to attend their mandated monthly health screening and pep talk, then, won't they?

I have a better idea. And get this: It's really cheap, requires no heavy handed regulations, no oversight (and who IS watching the watchers, these days?), no bureacracy, and no new federal departments or agencies. If you really want to motivate people to take control of their health, try telling them that the government is no longer going to pick up the tab for it, and then let them keep all the money that the government forcibly extracts from them on the public's health behalf. How do you think that would work? Eh? Too easy? Too many busybody, know-it-all, ignoramuses will end up without anything to play pundit about? Too many bureaucrats would have to find honest work? Too much heartbreak at letting go of your childish socialist utopian dreams?

Posted by: msoja | September 22, 2009 5:54 PM | Report abuse

I agree with the wisewon's manifesto.

My suggestions:
1. New medical doctors should be required to practice in low cost settings.
2. Health care IT should be nationalized.
3. Single payer.
4. Competitive bidding for drugs and other medical equipment.

Posted by: bmull | September 22, 2009 6:40 PM | Report abuse

Shorter bmull: The beatings will continue until morale improves.

Posted by: msoja | September 22, 2009 7:29 PM | Report abuse

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