It Is Time for Our Best Ideas for Our Health Care System | Commentary

Posted April 24, 2014 at 4:00am

The debate over the Affordable Care Act has demonstrated one clear fact: No one thinks our health care system is working as well as it should be for most Americans. There is agreement that costs are too high, quality is not as evenly distributed as it should be, and the way we pay our doctors, hospitals and other providers of health care just doesn’t work anymore.

Now is the time to seek out the ideas and policies that will begin to answer these tough questions. It is not the time to shut down ongoing programs that are testing ideas designed to solve these critical questions. Unfortunately that is what the Centers for Medicare and Medicaid Services is about to do with the Multi-Payer Advanced Primary Care Practice (MAPCP) demonstration program.

Over the last decade, CMS has been a key player in the testing of new and innovative ideas designed to better treat patients with multiple chronic conditions, who everyone agrees drive up health care costs and who can benefit tremendously from well-coordinated, quality care. The MAPCP demonstration program, which launched in 2011, is designed to help us address these key issues. But much like patients themselves, pilot projects like this do not fit neatly into a framework that has been drafted up back in Washington. Once reality hits, the best laid plans need to be adjusted based on new facts and information. As the MAPCP has unfolded, it has become clear that the original timeline for the program, which is set to expire this year, was misaligned with the goals and requirements of the initiative. Now, the program is at risk of being terminated before there has been any determination as to whether it is effective. This means three years of investment could essentially be lost and, worse, the important initiatives set forth by the program would be stopped in their tracks.

The MAPCP is an important example because the type of care it aims to facilitate is precisely what so many in the health care community say is imperative to reform. Under the MAPCP demonstration, CMS participates in multipayer reform initiatives currently being conducted by certain states (8 total) to make advanced primary care (APC) practices, or “medical homes,” more broadly available. CMS pays a monthly “care management” fee for beneficiaries receiving primary care from APC practices. APC practices are important because they utilize a patient-centered, team-based approach to care. This interdisciplinary approach to care avoids the silos that are far too common in treating patients that receive services across a variety of providers. Under this approach, APC practices focus on prevention, care coordination and shared decision-making among patients and their providers, especially helpful approaches for integrating care and aligning services for those with multiple chronic conditions.

While there has not been sufficient time to fully evaluate the effectiveness of the MAPCP program, the program administrators and those on the ground, including beneficiaries who receive services through MAPCP, are encouraged by the program’s developments and believe it is delivering the type of care that is focused on improving the quality and coordination of health care services for beneficiaries with chronic diseases. Though CMMI has requested a six-month extension for the MAPCP program, which would reset the expiration date from June 30, 2014, to Dec. 31, 2014, those operating the MAPCP programs in individual states feel this still does not leave enough time to ensure adequate evaluation. That adequate evaluation is critical to ensuring the efficacy of the program is fully understood and, if valuable, can be shared and scaled across the country — a prospect that, given the high cost of treating those with chronic conditions, could mean substantial health care savings that would more than offset the cost of extending the demonstration program. In fact, one of the main charges of CMMI and a key factor intended to differentiate its efforts from those before it, is its commitment to expanding successful projects to the entire Medicare population. Ending projects too soon will undoubtedly compromise this goal. It is imperative that CMMI be flexible and considerate of this important end-goal by establishing needed processes and criteria to help grow successful demonstration projects beyond their original scope.

Ultimately, testing of complex delivery and payment innovations is, and should be, an iterative process. Unless and until there is clear indication a model will not work, it is important there be flexibility in adapting new models and holistic consideration for what may be gained or lost from continuing or halting a particular project. CMS and participating entities, such as individual states or medical practices, invest significant resources in any given project, and thus decisions to end a project and undercut this investment must be weighed with careful scrutiny.

To ensure the success of investments in innovation, such as the MAPCP, and best support the shift toward a more effective and efficient health care system, it is imperative that CMS, and others currently testing new methods of delivering and paying for care, carefully consider how their decisions will affect our ability to fully realize the value of innovations.

Kenneth Thorpe is the Robert W. Woodruff Professor and Chairman of the Department of Health Policy and Management at Emory University.