Multilevel Interventions in Health Care Conference: Presentation by Kelly Devers, PhD
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Multilevel Interventions in Health Care Conference: Presentation by Kelly Devers, PhD

it’s my pleasure to introduce Kelly Devers. Kelly is
a senior Fellow in the Health Policy Center at
the Urban Institute in Washington, D.C. Dr.
Devers’ current research focuses on the implementation
of national and state health policy reforms. And that’s
kept her very busy. She’s particularly related to
patient centered medical homes, accountable care organizations,
and related provider payment changes. Hospitals and medical
groups efforts to improve quality and efficiency through
the use of electronic medical records and process
redesign techniques, and efforts to improve the
quality of cancer care in community hospital based
cancer centers. That’s a lot. She does a lot and we’re
glad to have her here. She earned her Ph.D. from
Northwestern University and I think she’s very much in touch
with what’s going on with health care reform, and through
the Urban Institute and through the activities that are
going on in Washington, D.C. So we look forward to hearing
from her and having her contributions incorporated
into the journal. Away we go.>>>Kelly Devers: Thank you so
much for the introduction and it’s really a pleasure
to be here. I rarely, after hearing about evaluations
I’ll do my best to keep us on time and keep you entertained
this morning. I want to take a minute to acknowledge my
co-conspirators in this paper. Dr. Baronson who is at the
Urban Institute with me, Mary Fennell and Ann Flood. But
I take all accountability for any flaws in the talk today.
Our purpose was really to try to identify, describe and
discuss some key provisions of the Affordable Care Act and the
federal stimulus bill known as the American Recovery and
Reinvestment Act. In particular I want to focus on new
care delivery models, new provider payment models
that often are accompanying those changes in delivery, and
health information technology. I want to highlight and try to
draw out their impact on cancer care and implications for
research. I don’t want to keep you in suspense so I’m going
to hit my major themes and takeaways right
now. First of all, I think we all as
Arnie alluded to and said, big changes are underway with
the historic passage of the Accountable Care Act. And
as Dick Scott reminded us, that’s not going to sort of,
that didn’t happen the day President Obama signed that
piece of legislation. We are in the early, early phases of the
implementation of that historic piece of legislation. The
political and economic and other legal realities of the
legislation are continuing to be debated at many levels
and will continue to play an important role in how that bill
is eventually implemented but over the next decade or so.
So we are at the very early stages, but we do anticipate
big changes. It won’t be business as usual. It will be
influencing multiple levels of our health system and in
fundamental areas. As some of you might know, the Accountable
Care Act really focused on two fundamental areas, coverage and
coverage decisions. And then the organizational delivery
of care. But what I mean by coverages, who will have
access to health insurance, what kind of insurance company
is going to cover them. And in terms of coverage decisions,
things like what technologies and services are going
to be paid for and how, comparative effectiveness and
other kinds of techniques are going to play into those
coverage decisions moving ahead. The second major
component of the legislation focused on the organization
and delivery of care and the related provider payment
changes. And that’s really what I’m going to focus on today.
But I do want to point out that those major changes in coverage
will impact the organization and delivery of care also
in terms of the fact that we potentially have 30 million
more Americans covered under insurance. And there will be
tremendous pressure on access as well as keeping
costs under control, as well as keeping quality
up, or maintaining or improving quality. So that brings me to
my second point. Basically the changes underway will impact
cancer care in significant and highly unpredictable ways. We
are in an incredibly dynamic period. The health system
is particularly complex and dynamic, and we can pretty much
expect unintended responses and consequences. These times and
changes require big science, and I’m sort of, stick with me
here. I want to take a minute to say what I mean by big
science. I think the most concrete example of big science
that we have is the human genome project in health care.
That was started in the 90’s and really represents a
historic and major investment by the government in scientific
research to sequence the human genome. We have had big
science, that term was coined right after World War II,
where the government got involved in significant
way in basic research. And in a historically
unprecedented way, the government was playing
a major role to develop the infrastructure for
scientific research, including investment in
major pieces of equipment, laboratories, training, all the
like. So our current example in our health world is the human
genome project. And what we’re calling for is certainly not
big science of the magnitude of the human genome project,
but thinking in terms of both mentality and the
infrastructure necessary to do large scale projects in terms
of the organizational delivery of cancer care and its impact
on outcomes for patients. So with that said I want to give
you some concrete examples of some changes underway in the
delivery system and what it means for cancer care. First
of all, what is a patient centered medical home? Well,
some would say it’s a really good primary care practice
plus, and we have some experts here, Kurt Stange and others
who are doing great work in this area. And the purpose
is to support and improve primary care, particularly
access, patient centers, care coordination and
management. There are literally dozens of specific patients in
a medical home definitions out there and numerous assessment
instruments. But they share seven common principles.
Personal relationships, whole person orientation,
team delivery of care, care coordination
across specialties, care settings and time,
quality and safety improvement, enhanced access, and adequate
and/or new payment models to support these changes. We have
a lot of activity underway with patient centered medical homes.
Recently CMS announced its support for the advanced
primary care demonstrations, and I know that work is
underway to get that off the ground. In these
demonstrations, Medicare will be joining
multi-payer medical home efforts in eight states around
the country. We also have multi stakeholder pilots of medical
homes underway already in 18 states, and there are currently
39 Medicaid associated patient centered medical homes. Some
are exclusively Medicaid or CHIP for kids, and others are
parts of multi-payer efforts with commercial health plans.
What is the potential impact on cancer care?
Well, one question is, are primary care providers well
suited to serve as the medical home for cancer patients and to
coordinate the cancer care for their particular patients that
might have cancer. The second question is, can oncology
practices and oncologists be a medical home. There is a
vigorous debate right now in the literature about
whether specialties, different kinds of specialties
including oncologists, could serve as a medical home.
Aside from that question, how do we encourage and support
positive aspects of medical homes in oncology practices,
regardless of what we call them, how we pay them. Things
we want to encourage like patient (inaud.),
shared decision making, care, integration
and coordination, how can we encourage that
in oncology practices or on multiple different types of
oncology practices that are typically involved in a single
patient’s care. And how might medical homes effect
multi-disciplinary care in cancer teams. A second major
delivery system model underway is called an accountable
care organization. And again, I ask you to bear with me
because this is an abstract concept, although I’m sure all
of you have seem some version of an accountable care
organization in your area. But there are some significant
or notable changes to what you might already be familiar with.
And one simple way I say this is, some people ask me,
is it an accountable care organization an HMO in drag?
Or isn’t it an integrated delivery system, or is
it a this. And I say, well it can be all
of those things, but there are some important
differences. I’m going to try to be clear about what the
differences are. Okay. An accountable care organization
attempts to couple provider payment and delivery system
reforms together. It attempts to solve a chicken
and egg problem by, in the sense that
people will say, well we can’t change our
delivery system because we haven’t changed our payment
models. And people in the payment model side say, we
can’t change our payment system because there are no provider
organizations able to accept the kinds of payments we
would like to give to them. Like different kinds of
risk adjusted payments, bundled payments, other
things that would require the organization to take some
accountability for a broader spectrum of care and manage
the care and the dollars. So we have this conundrum. The
ACO attempts to couple those things together. Another
critical feature is that an accountable care organization is
a form of direct contracting between Medicare or
purchasers, and providers, cutting out Medicare plans.
As you might have seen in the health care reform debate,
plans were not seen as the heroes of the future. We feel
like we’ve gotten very little in some ways for our money from
health plans. There are some good ones like the
Kaiser Permanente’s, but there were a lot of ones
that we couldn’t quite see the value. The
purpose here is to say, Medicare contract directly
with the set of providers. You providers help manage the
dollars and the quality of care (inaud.) help manage the
risk. So it goes directly to providers. ACO’s are purposely
designed to be flexible. People say, we don’t know what
the right delivery system model is, let’s experiment, let’s let
flowers bloom or things related to regional areas come up from
the ground. So we understand that there’s a lot of
variation in local markets, and we need to experiment, we
need to build on that variation cross market in terms of
provider organization’s capacity and willingness to
accept non-fee for service payments. And we need to
experiment with new payment methods. An accountable
care organization then is only broadly defined as a group
of providers specifically, or at least
including, primary care, specialists and hospitals that
can be jointly held together, held accountable for the
quality and cost of care. So they at least have to have
a legal umbrella and a legal infrastructure that says we’re
working together and are going to accept responsibility
for these 10,000 Medicare beneficiaries. They
don’t have to be owned by the same organization, they can
stay in all kinds of different configurations. So this picture,
or this figure really is just designed to give you a
quick sense of two things. One, there are very
different models of who might lead an accountable
care organization. Everything from a set of
primary care physician groups who then will go out and
get the specialist thingy, or decide what hospital they’re
going to contract with. To something that we’ve seen
before in organized delivery systems that owns and operates
already all of these pieces. Up in the blue box is
tertiary or quaternary care, and this is important because
we recognize that in certain areas of the country patients
are still going to want to go to academic medical centers or
other kinds of centers out of the area or out of their
accountable care organization network. We want patients to
have the freedom to do that. But if the accountable care
organization has a strong incentive to keep
total costs in check, and they have quality metrics,
they may want to keep those patients inside their own
accountable care organization network. So it has the
potential to change referral patterns to academic medical
centers and NCI designated centers, etc. So, the first
step of ACO pilot is well underway, and we expect the 800
page rule to be out in the next month. So there will be
plenty to look at in terms of the details of this program. And
there is significant interest in this pilot by providers
as well as public and private purchasers. I think I’ve
already alluded to the impacts on cancer care. These sets of
providers will have a greater incentive to reduce total cost
of care. The strength of the incentive will vary by
the specific models, payment models allowed under
the pilot. And they alter referral patterns. There
will be more incentive to meet quality targets and hence a
greater need for an emphasis on risk adjustment and quality
measures to protect against stinting on care. We really
want to try to understand to what extent will
academic medical centers or NCI designated cancer centers be
able to lead or participate in an ACO, and learn
how the hospice, nursing homes or other kinds
of services fit in here. As you might imagine,
any change in payment, like episode based
payments for cancer care, leads to debate. Significant
debate. That’s all I need to say about that. EHR’s. Most of
you know what electronic health record is. The largest
investment by the federal government through
our High Tech Act, approximately $30
billion, to facilitate, adapt and upgrade, and
meaningful use. There’s a lot of detail in what we
mean by meaningful use, but it’s essential evidence.
Things that the government feels is evidence based uses
of an electronic health record that will lead to quality and
efficiency gains. So you can’t just buy an EHR and
stick it on your, put in your office and not use
it in these ways. And there’s a variety of ways the government
will be monitoring the use to make sure providers are
getting payments to use it appropriately.
Electronic health record, as you might see
from the diagrams, isn’t very good if I can
only have it in my office and I can’t exchange data with the
hospital or specialist. So health information exchange
and building that information highway is critical and also
underway. We ultimately hope to increase quality and efficiency
in patient centered care in a secure environment. But as you
know it’s highly complicated, so many oncology practices are
underway trying to make this complex technology work in
their practice. And it may have disruptive and unintended
effects. Health information exchange provides new
opportunities to share information among oncologists,
hospitals and researchers. But also there’s many technical
challenges and concerns about privacy, security, and related
legal matters. Punch line. Implications for research,
basically what are the impacts of patient
centered medical homes, ACO’s, and health
information on integration, care coordination across
the continuum in these key outcomes. In our patient
centered medical homes and accountable care organizations,
complementary or conflicting. And how do EHR’s and HIE
fit into the patient centered medical home in ACO’s. A lot
of the assessment tools for the patient centered
medical homes, for example, require electronic health
record capacity. In some, in terms of our topic, in
terms of multi-level research, I think, I hope I’ve given
you some sense that these are, these major delivery system and
payment reforms underway are very complex. They will
play out differently across the country. They’re
multi-component and they’re multi-level. Federal, state,
local, region, market, down to hospitals, practices,
down to the patient level. Now methods must match the
times and our current multi-component, multi-level
research toolkit has some areas of strength and progress,
but also some serious gaps. And I would argue we need
big science, we need a comprehensive approach.
Work in one area methods or data, or some of these
areas alone won’t do it. We need larger scale
projects and larger investments to bring teams of researchers
and perhaps centers together in a broad scale approach to
meet the needs of the field of researchers and
diverse policy makers, payers and providers.
As well, of course, patients and local
communities. Thank you.>>>[APPLAUSE]>>>DR. STEPHEN TAPLIN: Thank
you, Kelly. I think it makes it clear that we have a future,
there is a future set of questions, and a future world
which is going to be quite different than what we’re used
to. And I think that’s an important motivation for
thinking about what we’re doing and how we’re doing it,
and how we move forward. So I think that’s a critical
background and I’m glad to now have it incorporated
into the meeting.

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