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Berwick, with HHS Secretary Kathleen Sebelius to his right, announces the Partnership for Patients initiative earlier this year.
Berwick, with HHS Secretary Kathleen Sebelius to his right, announces the Partnership for Patients initiative earlier this year.
Photo credit: JAY MALLIN

Recruiting agents of reform

CMS healthcare program seeks innovators at local level

By Jessica Zigmond
Posted: November 7, 2011 - 12:01 am ET

Will a new $6 million endeavor be strong enough to help change how an $800 billion federal program has done business for more than four decades?

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CMS officials are confident and healthcare industry leaders are hopeful that the Innovation Advisors Program—intended to help leaders gain the skills to carry out system reforms for Medicare, Medicaid and Children's Health Insurance Program beneficiaries—will improve healthcare services in communities nationwide, and, in the process, help the agency achieve its three-part aim of improving care, bettering health and lowering costs.

“This is part of a sea change in how CMS is viewing their role,” said Stuart Guterman, vice president of payment and system reform at the Commonwealth Fund. “Until recently, Medicare's role has been to pay the bills. In the last 10 years, Medicare has been seeing its role—more appropriately, I think—as providing access for their beneficiaries to the care they need.”

Experts say the Innovation Advisors Program—which is funded through the Patient Protection and Affordable Care Act but is not a demonstration project—is different from other initiatives because it will seek and develop leaders within organizations who understand their local environments and marketplaces, as opposed to bringing outside players into the mix.

“If we treat this as top-down, we're not going to be successful,” CMS Administrator Dr. Donald Berwick said in an interview last week. “We need a community out there of alert, excited, proud and locally wise leaders who can both hear about innovations and say, ‘This can work here,' and adapt the innovations to local context.”

Overseen by the CMS Innovation Center, the program will select and develop as many as 200 participants in the first year to help them sharpen their skills in healthcare economics and finance, population health, systems analysis and operations research. In turn, these advisers will support the Innovation Center in testing new models of care delivery and building skills throughout their organizations and areas or regions.

The program is one of many system-reform initiatives included in the Affordable Care Act and under the direction of the Innovation Center created by the law, such as the $1 billion patient-safety initiative called Partnership for Patients and the Comprehensive Primary Care Initiative, a program aimed at improving and expanding access to primary care in partnership with private insurers.

With the advisers program, the idea is for participants to adopt new models and adapt them in their own communities. “These people will be nominated in conjunction with a hospital, practice, or other organization,” Berwick said. “That organization will receive a stipend of $20,000 to support that person for about a day a week.”

Applicants for the first cohort are due Nov. 15, and the CMS will choose 50 advisers for this group. There is no application deadline date yet for the second group—which will be a cohort of 150—but the CMS expects this to be in the late winter or early spring, said Joe McCannon, senior adviser to the CMS administrator.

The program's training will consist of face-to-face and webinar-based sessions that will be integrated with the projects the advisers will work on, beginning with the ones they propose in their applications, McCannon said. For the first six months, they will work on projects in their home communities, and in the following six months, they could help the Innovation Center on other projects.

“Once these folks have deepened their skills in their own area, we'd like to use them as a source of knowledge and help coach others who are trying to make similar change or transformation,” McCannon said, adding that these advisers will be assets to the Innovation Center in the future. “They'll help us harvest ideas and insight, and we might suggest to them that they support some of the models we're introducing in the field."

Participants must meet certain criteria, and Berwick emphasized that the program seeks to help participants who have “charisma, presence and gravitas” become local leaders. He also hopes the program will be diverse with regard to gender, race and region of the country, and he wants them to be active in designing and implementing the curricula for the program.

“The plan is to get the first advisers in early and become teachers themselves,” he said. “The innovation advisers are out there already inventing something wonderful and they are already an expert on patient safety, or coordinated care, or prevention,” he added. “We need to make them not just learners, but teachers.”

This idea of innovation from the inside out is one of the program's strengths, Guterman said, adding the CMS will ultimately benefit from learning how healthcare can be improved from those inside various organizations.

“Frequently, what government agencies and private payers do is work outside the delivery system and provide carrots or sticks to make the system move in a particular direction,” Guterman said. “This looks like it's taking a more direct approach—that it's actually working with people in the system, rather than creating incentives outside the system.”

For the program to be successful, the CMS will need to select good people whose organizations are willing to make changes, Guterman said. And it will take a lot of interaction between the CMS and these systems to help them achieve their goals, as each organization has a different configuration, marketplace and local environment. Guterman drew a parallel between this program and the Health Information Technology Extension program under HHS' Office of the National Coordinator for Health Information Technology. These centers, funded through the HITECH Act, offer technical assistance, guidance and information on best practices to help healthcare providers become meaningful users of electronic health records.

“It's one step to be willing to reward them,” Guterman said. “But it's another to show them how to go about doing the right thing to get those rewards.”

Guterman, who served as director of the CMS' Office of Research Development and Information from 2002 to 2005, said he thinks the program is a “terrific” use of $5.9 million in federal dollars, and he placed the funding in the following context: If the Medicare and Medicaid programs are estimated to spend $812 billion in 2011—as the Congressional Budget Office projected in its March 2011 baseline—that would mean the agency would spend the amount allocated for the Innovation Advisors program in just under 4 minutes (or, to be more precise, 3 minutes and 53 seconds).

But others question if the program can succeed in a bureaucratic system.

“In the current structure of Medicare, how effective will it be?” said Robert Mofitt, senior fellow in the Center for Policy Innovation at the Heritage Foundation, a conservative think tank on Capitol Hill. “A government program is a political affair, no matter how you cut it,” he added. “If you try something new and different and innovative, what happens when that runs into the Medicare industrial complex?”

As an example, Mofitt noted that although the Medicare program was established in 1965, there really wasn't a change in benefits until the Medicare Modernization Act of 2003 brought with it the prescription drug benefit. That's because decisions about benefits or payments either happen at the administrative or congressional level—and, ultimately, they are political decisions, Mofitt said.

“No well-intentioned program can overcome the dynamics of a system that is based on central planning and micromanagement,” Mofitt said. “You could get innovation advisers that are the most brilliant in the world, but if it compromises some powerful insurance group or provider group, the chances of it surviving through the Washington machine is very unlikely.”

The influence that healthcare industry groups have on Washington is significant. The Center for Responsive Politics issued a report last week that showed more than 400 companies reported lobbying the powerful Joint Select Committee on Deficit Reduction, better known as the supercommittee, during the third quarter of this year, with 118 of those groups, or about 30%, coming from the healthcare sector.

Others are hopeful that the program can work, including Toni Mills, executive director of the Office of Clinical Affairs at the Blue Cross and Blue Shield Association. An employee in Mills' office has applied to the Innovation Advisors Program, and the association hopes its participation will allow the group to help about four or five of its health plans in rural areas—in the Southeastern U.S.—work with local provider groups, and hospital associations to help improve quality and lower costs.

The Blues association is familiar with programs that share and replicate best practices; in October, the association unveiled Building Tomorrow's Healthcare System: The Pathway to High-Quality Affordable Healthcare in America, which cites examples of programs that Blues plans have implemented across the country. The Innovation Advisors Program is appealing, Mills said, because “they're going outside to the general public to look for innovators.”

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