“There is more than a realization; there’s an acceptance that we are going to have to do less with less. The idea that we’re going to keep getting payment levels going up and keep doing more for patients with more resources, it’s OVER … We’re going to do less with less with superior outcomes … The pressures are going to be intense.”
Bruce Siegel, National Association of Public Hospitals and Health Systems
The innovations featured during the Million Hearts™ event have the potential of contributing to the initiative’s ambitious goal of preventing a million heart attacks or strokes, if they spread widely across the many health care delivery organizations in the country. As noted in the sections above, the spread of these and other innovations depends on getting the innovations ready for spread and activating the relevant stakeholders that can affect the ability of adopting organizations to successfully implement the innovations. In addition, successful spread must recognize the widespread impetus to transform the health care ecosystem in fundamental ways.
This push toward transformation has been coalescing over the recent decades, with growing consensus that the country’s costly health care system delivers only mediocre outcomes. For example, a recent report by the Commonwealth Fund (2011) notes that, despite having the most expensive health care system, the United States ranks last overall compared with six other industrialized countries—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—on measures of health system performance in five areas: quality, efficiency, access to care, equity and the ability to lead long, healthy, productive lives.
The need to obtain more value from health care investments becomes more acute given the national (and international) economic pressures. State programs are particularly vulnerable. As Diane Justice (National Academy for State Health Policy) said: “What’s not sustainable … are programs that are funded with state general revenues, funded with Federal block grant funds. All of those are shrinking.”
Health reform in the public and private sectors may continue to generate tremendous incentives for delivery and payment changes, as well as certainly enlarge the patient population who will demand care. Thus, the system will be challenged to find new avenues to augment the already short supply of primary care physicians to deliver basic health care services.
In recent years, we have seen increasing experimentation in new approaches across the health care delivery spectrum. Experiments in new delivery and payment models, such as Patient-Centered Medical Homes and ACOs are being explored. With government support, various states, including New York and California, are moving toward creating incentive structures that are oriented toward value and patient outcomes. In these experiments, payment models are evolving from the traditional volume-based fee- for-service models to new outcome- and value-based models. Many of these experiments are taking advantage of new technologies that can make and facilitate the use of information more efficiently, easily, and inexpensively.
The discrete cardiovascular innovations featured in the Million Hearts™ event focus on specific and bounded microsystems within the health care systems. Scaling and spreading these innovations will be facilitated by exploring possible integration into these larger experimental models, which will likely become part of the health care landscape in the near future.
“This is one of the things that makes the spread of innovation so hard in health care—the status quo is formalized into the payment system, so we get paid to do what we’ve always done.”
Paul Plsek, Paul E. Plsek & Associates, Inc.
Many innovative services are not covered under the traditional fee-for-service payment model. The Million Hearts™ innovations highlighted the challenge of spreading services that are not now reimbursed by third-party insurers. Business groups are concerned with these gaps. In the words of Veronica Goff, from the National Business Group on Health, “[Innovative services] are the kinds of things we want to buy … but we are not really set up to pay for these right now. We’ll need to address that.” Moving away from volume-oriented fee-for-service payment systems toward new global models that combine elements of existing capitated payment systems with performance-based incentives was seen by participants as necessary for the spread of the Million Hearts™ innovations. For example, the Heart360® program was successfully implemented within the Kaiser Permanente system, which has a capitated payment system. Implementation of this program under fee-for-service systems will be difficult, as most insurers will pay only for office visits, not for the home blood pressure monitoring that is at the core of the innovation. Scaling innovations like Language Concordant Health Coaches will also run into payment issues, since insurers will not usually reimburse for the services of health coaches and other types of “physician extenders” who can improve access to care for many types of patients, especially those outside of the linguistic or cultural mainstream. Again, implementation of the Language Concordant Health Coaches innovation in San Francisco has been facilitated by the UCSF capitation payment system.
While capitation is seen as a solution that will address many challenges to paying for innovative services, other approaches were also offered. Certain innovative services may spread within supportive, but narrowly defined settings. For example, the Medication Therapy Model originating in Asheville, North Carolina, has been adopted nationwide by more than 60 self-insured employers. Dissemination outside the self-insured employer segment has required creative negotiations. In one municipality, Blue Cross Blue Shield implemented the Asheville program using a carve-out (i.e., an approach that provides coverage for specific health care services under funding separate from general health care services). Medicaid waivers provide one path to funding these kinds of services. Waivers have been negotiated in various states to cover specific services outside of the main contract. In California, for example, Hali Hammer persuaded state Medicaid offices to cover the costs of health coaches, arguing for the Health Coaches’ benefits to Medicaid populations and cost savings to Medicaid programs.
Apart from issues related to volume-oriented fee-for-service systems and outcomes-oriented global payments or capitated systems, payment structures also create misaligned incentives. Benjamin Bluml, speaking about his organization’s efforts to spread the Asheville model, said, “The challenge we’ve continually seen is to get payers to … properly align the incentives so they can improve the outcomes and control the costs.” Pressures exist to deliver services which are reimbursed, even if these approaches are not necessarily the most effective or efficient. Referring to the temptation to follow the revenue, even in mission-oriented teaching hospital settings such as the San Francisco General Hospital Family Health Center, Hali Hammer said, “We take care of a lot of uninsured people. So whenever we saw a person with Medicaid, bingo. We’re getting a lot of reimbursements, so why would we want to have a health coach talk to them rather than having them come back for an office visit? We all knew that was not the right way to provide care, and we didn’t do that.”
Incentives are also misaligned with regard to timing. Costs for implementing innovative practices, as well as payments for these services need to be paid up front, but in many instances, the benefits are accrued many years later. The Heart360® innovation, which requires payments up front for blood pressure monitoring in order to prevent heart attacks many years later, is an example of this issue. Given the high level of customer turnover in the health insurance industry, insurers who pay for preventive services may not realize the savings accrued from avoided illnesses many years later.
Million Hearts™ experts agreed that the payment systems for health care must change in order to provide for new services that would improve outcomes, while reducing costs. Million Hearts™ experts also suggested it may be useful for such innovative programs to connect with pilots that involved some form of global payment, such as demonstrations of Medical Home or ACO models. As noted previously, the tide is turning, albeit slowly, toward payment structures that incentivize providers on value rather than volume. These emerging structures will facilitate the spread of innovations that are not covered by traditional fee-for-service payment schemas.
The Changing Healthcare Workforce
“The only way, in this country, we’re going to be able to improve quality, reduce cost and preserve employment in the health care field is by using every member of the team to their fullest potential, to the top of their license …”
Thomas Frieden, CDC
Already there is a shortage in the supply of primary care physicians, and this shortage may become more acute with the health reform initiative when many currently uninsured individuals obtain health insurance. One solution to this shortage is using other clinicians who can carry out some of the functions that have traditionally been reserved for physicians. The innovations featured in the Million Hearts™ event provide examples of workforce changes that could become standard in the health care system of the future.
Changes in Clinicians’ Scope of Practice
Several innovations featured in the Million Hearts™ event involved innovative pharmacist services, with these clinicians in roles beyond their traditional boundaries. In the case of the Heart360® program, pharmacists monitor home blood pressure readings, adjust medication (with general physician oversight) and provide counseling to hypertensive patients. These expansive functions were allowed in Colorado—but not in all states—where pharmacists’ scope of practice includes the ability to adjust medication regimens and provide other treatment. As of May 2011, at least 44 states authorize physician-pharmacist collaborative practice agreements to provide drug therapy management for any health condition specified in a written physician protocol (Odum and Whaley-Connell 2012).
Related to scope of practice changes, new provider categories, such as the “clinical pharmacist practitioner” designation can be created. Paralleling the designations of Nurse Practitioners and Physician Assistants, Clinical Pharmacist Practitioners are considered medical providers who are approved to provide reimbursable drug therapy management services. They are “experts in the therapeutic use of drugs, who are primary sources of scientifically valid information and advice and who generate, disseminate, and apply new knowledge that contributes to improved health and quality of life” (Saseen et al. 2006).
Broadening roles of various types of clinicians can require adjustments on the part of physicians who may have traditionally considered certain functions as exclusively belonging to physicians only. Adjustments are easier when physicians see these changes as easing their own burden. Instead of viewing these changes as infringements on their scope and authority, physicians may see them as mechanisms to allow them to focus on more complex medical tasks.
Clinicians whose roles are newly broadened may also need to adjust to these new requirements. Barry Bunting, who has worked tirelessly to promote the Asheville-based Medication Therapy Management innovation said (video interview), “As a pharmacist, we typically think of ourselves as providing a product: medication. There needs to be a greater emphasis on the service—the knowledge that goes along with that product, improving outcomes—not just providing a product.”
Use of Non-Clinician Aides
“It’s the Clayton Christensen idea of trying to … find someone less expensive [and] more accessible. So you’re always looking for other ways of doing things in a less expensive and more accessible [way] and whatever that is, [using] a pharmacist, a nurse, [or] a trained volunteer even in some cases.”
Paul Plsek, Paul E. Plsek & Associates, Inc.
As noted above, innovative definitions of the scope of clinician practice can generate improvements in access and quality of care, as well as reduce costs. Further improving the workforce value proposition, a variety of paraprofessional roles are emerging to augment the traditional roles of medical professionals. The health coaches used at San Francisco General Hospital Family Health Center is one example of these new developments. Other paraprofessional roles include “promotoras” (community health workers often utilized in Hispanic/Latino communities), health system navigators, and peers/volunteers. Not only do these roles provide personalized connections to the often fragmented and inaccessible health care system, they often go beyond the usual narrow boundaries of medical care, approaching individuals holistically and connecting them to other needed services such as transportation and housing.
Team-Based Care and Cultural Competency
Team-based care that is sensitive to the needs of different segments of health care customers is core to many service delivery innovations. Pressures toward efficient care delivery and growing demands for higher quality coordinated care have created the realization that providing high-quality health care is a “team sport.” In the Asheville innovation on medication therapy management, for example, pharmacists work collaboratively with physicians. In the Health Coaches innovation, health coaches work in tandem with medical residents. Training for health care professionals has been slow to include this perspective in its curricula, although recent initiatives such as the TeamSTEPPS® delivery system (developed by AHRQ and the U.S. Department of Defense) have started to address this gap among practicing health care professionals.
Similarly, there is a growing realization that cultural sensitivity is a desirable competency for health care professionals and their organizations. According to Robert Like, Robert Wood Johnson Medical School, some states (e.g., New Jersey, California, New Mexico, Washington, and Connecticut) have included cultural competency in licensure requirements for physicians. Insurers such as Aetna and Blue Cross Blue Shield now offer Continuing Medical Education (CME) credits for cultural competency training, although uptake is still reportedly slow. Recently, the Joint Commission, the National Committee on Quality Assurance, and the National Quality Forum have developed initiatives to address health disparities and cultural competency at the organizational level.
Million Hearts™ event participants emphasized the importance of providing stronger incentives, perhaps even mandates, to enhance the skill sets of current health care professionals in areas like cultural sensitivity. Christine Heasley of Highmark pointed to their pay-for-performance program for medical offices that incorporate best practices to eliminate health care disparities, including cultural competency training. At the same time, the Million Hearts™ experts pointed to the need to integrate these topics into the earlier education of medical professionals. Fran Griffin from the CMS Innovation Center said, “We’re getting to people too late … To really go forward successfully with these types of initiatives, we need to get to physicians, pharmacists, nurses, physical therapists … while they’re in their training programs …. This is a fundamental part of your education.”
New Provider Organizations
“The increasing presence in the marketplace of our large pharmacies, Wal-Mart, Target, Walgreens, and retail clinics … they are seen as the new wave of primary care providers.”
Lisa Simpson, AcademyHealth
Not only is the workforce for delivering health care services changing, but so are the institutions involved in providing care. The number of retail clinics has burgeoned since 2005, representing a new channel for delivering health care services more conveniently and economically (Deloitte Center for Health Solutions 2009). Most retail clinics are located in local pharmacies, but increasingly they have been emerging in other settings, such as grocery stores and big box retailers. Retail clinics have even moved into airport settings in Atlanta and Philadelphia.12 Typically staffed by nurse practitioners or physician assistants, these clinics have gained favor among health care consumers because of their accessibility and speed of service, and they have been particularly convenient for the uninsured.
Retail clinics provide basic primary and urgent care services in places and times that meet people’s simple health care needs. They may provide important ways to augment the current and increasing shortage of primary care providers. While initially, there were fears that retail clinics would substitute for traditional health care providers, their complementary nature has become clearer in recent years. These clinics have started to align with physician practices as well as large acute care health systems, including the Mayo Clinic in Minnesota, Cleveland Clinic, and the Allina hospitals.
These types of alignments may be the wave of the future, aligning with the trend toward integrated ACOs, making it clear that retail clinics can complement, rather than replace, traditional providers of health care services.
12 Airport Clinics Provide Quick Access to Low-Cost, Routine Services for Travelers, Airport/Airline Employees.https://innovations.ahrq.gov/node/4311