ACP: Health care innovation in the Affordable Care Act

A guest column by the American College of Physicians, exclusive to

by John Tooker, MD, MBA, MACP

ACP: Health care innovation in the Affordable Care Act The Patient Protection and Affordable Care Act (PPACA) has important provisions – improved access, safety and quality among them – that have the real potential to improve health and health care and, lower costs.

Two recent reports remind us of the urgent need to improve safety and quality: A report from the American College of Asthma, Allergy and Immunology (ACAAI) 2010 Annual Scientific Meeting on the national state of the care of patients with asthma, a bellwether chronic illness that can and should be managed well for most patients in ambulatory settings, and the HHS Inspector General’s report on adverse hospitalization events of Medicare beneficiaries. Coincident and timely with the release of these reports, the Center for Medicare and Medicaid Innovation (Innovation Center) was established this month.

At the 2010 ACAAI scientific meeting, Meltzer and colleagues from the University of California at San Diego reported the largest and most comprehensive U.S. asthma survey since 1998, asking patients (adults and adolescents) how well they perceive their asthma is controlled. As a pulmonologist, I found the results disappointing. Though there have been advances in asthma care over the past decade, asthma unfortunately remains poorly controlled with many patients describing frequent asthma symptoms, using rescue medications for chronic symptom control and not using maintenance controller medications as prescribed – with substantial adverse impacts on patient well being, productivity and health care costs.

The HHS Office of The Inspector General is required by law to report to the Congress on the incidence of never events among Medicare beneficiaries, the payment for services in connection with these events, and the CMS processes to identify the events and deny payment. The recently released 2010 report examined the records of Medicare patients discharged from hospitals in October 2008 – 1 in 7 patients experienced an adverse event (13.5%), and remarkably, 44% of the events were viewed as preventable. The related additional costs to Medicare just for the study month were substantial – estimated at $324M.

On the same day as the HHS Inspector General released his report, CMS Administrator Dr. Don Berwick and Dr. Richard Gilfillan, Acting Innovation Center Director, announced the new Center for Medicare and Medicaid Innovation, established in the 2010 PPACA. According to Gilfillan, the Center will identify and test care models that provide beneficiaries with a seamless care experience, better health and lower costs.  Aimed at improving care coordination, the first initiatives of the Innovation Center are:

  • An eight-state multi-payer medical home demonstration
  • A new medical home demonstration involving Federally Qualified Health Centers (FQHCs)
  • A new state plan option allowing states enhanced Medicaid funds for placing certain beneficiaries in health homes
  • An opportunity to improve care for beneficiaries eligible for both Medicare and Medicaid, also known as “dual eligibles”

The evidence is clear that we need to perform much better on both quality and safety. In response to that need, we have a well resourced national opportunity – the Innovation Center – to improve the care and health of each patient, of the population at large, and lower costs, through innovations in care delivery and payment. Success, as Drs. Berwick and Gilfillan have identified, will require the active participation and leadership of doctors and other key stakeholders.

John Tooker is Associate Executive Vice President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • Ed Pullen

    So how does the ordinary practicing physician participate in any innovation to improve care? Guess not.

  • Juliet K. Mavromatis, MD

    Dr. Tooker, I enjoyed your blog. I recently left a large group practice where I routinely took care of asthma patients (& diabetic patients) who slipped through the cracks in terms of receiving guideline based care. In that practice we took a team based approach with diabetics. Now I am in solo practice. I have more time with patients, which I can afford because many patients pay an annual retainer fee to increase their direct access to and time with me. I have felt better able to review and provide excellent care to my patients, while communicating directly with their subspecialists–frequently over phone or email. Soon I will use my pricey EMR, which is communicating with a major hospital in my area, to generate reports on my performance with these chronic conditions. To Ed Pullen’s point, as a solo practitioner, what is the likelihood that I will be successful in convincing a payor to fund the extra time that it takes to provide this level of care within the next five years? I have gotten several emails from Georgia ACP calling for small practices to participate in a medical home pilot (I think with TransforMed) . However, rather than fund the practices who participate in this pilot, they are asking practices such as mine, to pay–can’t remember what the exact number is, but I believe it was around $8,000. It was interesting, but no thanks, I will need to do it on my own. Let’s hope PPACA will help protect smaller medical practices that would like to provide high quality care and be reiumbursed for the time that it requires.

    • Primary Care Internist

      Besides having extra time with each patient in such a retainer model, you also have the advantage of selecting for a more compliant, self-interested, and probably more educated patient base.

      The PPACA and health policy in general recently are perhaps going to have the opposite of the intented effect, by creating a less compliant and educated patient base left over to participate in medical homes etc., ie. those that are left over after taking away the more savvy folks in retainer-based practices.

  • Glenn Laffel, MD, PhD

    The differences between 1990s-style capitated payment models and Accountable Care Organizations are subtle, at best. Capitation had some successes, but they were sporadic. To assure ACOs are more effective in “bending the cost curve,” global payment schemes need to be aided and abetted by newer cost-saving technologies that are now at hand, things like telemedicine, home health devices (scales, glucose monitors w/data uploadable to the web), etc. These tools can allow care systems to leverage the services of PCPs and, over time, help care systems steer folks away from expensive specialist/hospital driven care.

    • Primary Care Internist

      Studies of visiting nurse management and similar such programs have, as far as i know, shown only marginal if any benefit in cost reduction or quality of life improvement. And these pretty much only look at CHF patients. Having scales, nurses, and technology at home sounds great. But it isn’t surprising that this doesn’t really save money, is it? And what doctor is going to receive and interpret all this info FOR FREE??? I, for one, am so sick of getting endless pages of “telemedicine” reports with q1 hour bp and pulse readings over 3 days from VNS.

  • Marc Gorayeb, MD

    Assuming, arguendo, that the OIG report is correct that 44% of the events were “preventable,” I still don’t see how medical or health ‘homes’ will improve patient health and safety WITHOUT also costing more in terms of physician and nursing time and effort. Can someone please cut through the jargon and lofty pronouncements and tell me exactly how this will happen?

  • skeptikus

    Dear Dr. Tooker,

    Your blind faith in bureaucratic, top down control of medicine is bizarre. Yes, the macro-data indicates that U.S doctors and the medical system lags far behind others’ in safety and cost-effectiveness, but what makes you think bureaucrats “know” the right answer–and can simply impose it with some type of reimbursement scheme that Medicaid dreams up.

    Medicine is characterized by information deficits. Doctors don’t really know what they’re doing–and measurement of success is difficult. If radically improving quality were so easy, it would’ve been done before. We’re here from Medicaid and we’re here to help . . .. ha, ha, ha.

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