Care Innovation Summit (Jan 26, 2011 in DC)

I was one of 1200 "healthcare innovators" attending the annual Care Innovation Summit last week, sponsored by CMS, the West Wireless Health Institute, and Health Affairs magazine.  The day started with a fantastic keynote by Atul Gawande, MD, and then there were assorted panels talking about healthcare innovations across the US. 
My thoughts and reflections on the day:

First, it was a good use of time.  It is hugely important to be able to hear innovation stories, and it is important the providers, industry, and government are all sharing with each other and trying to figure out this mess we call a healthcare system.  Additionally, the networking is always fantastic at a place like this.  I was able to see some old friends like Ted Eytan (Physician Innovator and awesome blogger), Margaret Laws (CHCF), and Carleen Hawn (Healthspottr), as well as meet some new friends who do great blogging, like Andre Blackman (Pulse and Signal) and Dr. Joseph Kim (Medicine and Technology).

Second, Gawande's keynote was really great - how can a surgeon be such a good writer and excellent speaker?!?!?  He focused a lot on the importance of creating easier systems which cost less and deliver all the appropriate care to as many people as possible. A few comments he made which stood out:

• Healthcare Costs are Killing the American Dream.  The "typical" US family has seen almost all of their increase in take home pay in the past decade go to paying for their healthcare costs. 
• We need Automation and Teamwork.  The complexity of healthcare is increasing exponentially but we have not really altered how we deliver care - one physician at a time.  In the past "2 generations" (about 100 years), we have expanded to over 13,000 known conditions, 6,000 meds, and 4,000 types of procedures - physicians have to know all these and then deliver them to every single American - not exactly efficient (and rarely consistent).   In other words, "We need Pit Crews, not Cowboys".  Every other industry has learned how to automate and task shift… it's time for healthcare to do the same!   [Side note... I think this is so important for the future of healthcare - that it is the basis of a new company I helped create in the past year... more to come later]
• We need better Data!  I love the analogy he gave… He said, "the way we currently provide data is like driving your car, but when you look at your speedometer, all you see is the speed of other cars from 4 yrs ago." We need to have real time data, specific to our needs!
• The Best Places Act like Systems.  He noted these three key skills are needed:
• The ability to recognize Success vs. Failure (i.e. need up-to-date data which is focused on a specific issue).
• The ability to identify failures and then devise solutions for them… he of course pointed out that you should consider Checklists to help organize the "best care".  I agree!
•  Make solutions easy to implement.  Keep them simple and cost-effective, and recognize the importance of consistency and teamwork.

Third, the government folks said that they know we have to become more innovative.  Dr. Richard Gilfillan (acting director of the CMS' Center for Medicare and Medicaid Innovation) said, "We need to decide now whether to make the commitment to adopt innovation that will fundamentally change the way we operate, change the way we deliver care, change the way we think about these organizations that we run. This is not an abstract notion; this is a very concrete question that each of us will have to answer."

Marilyn Tavenner (acting administrator for the Centers for Medicare & Medicaid Services) highlighted a variety of innovations, and expressed urgency in pressing forward with the “triple aim” goals of better individual healthcare, better population health and lower costs called for in the health reform law.

As a reminder, the summary of the Healthcare Reform law essentially comes down to four things: 

• Value: improve quality and cut costs  (and the part that is TOP on the mind of everyone)
• Access
• Insurance reform
• Medicare improvements

And the Triple Aim (as defined by Dr. Berwick) is:

• Better care (at an individual level) - including the STEEP criteria (Safety, Timeliness, Effectiveness, Efficiency, Equitable, Patient-Centered)
• Better health (at a population level)
• Lower costs

CMS also recognizes that the only way to do all this is for government and payors to better align incentives (hence the experimenting with ACOs and other reimbursement changes).  And as Todd Park (CTO for CMS) said, do anything they can to help America's "innovation mojo" heat up to start solving problems (such as by promoting the challenges below). 

Fourth, they released a series of private-backed Challenges throughout the day.  ONC posts these challenges at www.Challenge.gov/ONC.  Here are the ones announced at the Summit:

• Sanofi Diabetes challenge: www.datadesigndiabetes.com 
• JNJ-Janssen care coordination (hospital handoffs):  http://www.janssenhealthcareinnovation.com/connected-care-challenge
• KP HIV challenge: www.kp.org/hivchallenge  - actually more of a self-help tool for any HIV clinic in the nation to learn from what KP has done
• Allscripts CDS Challenge for CAD: www.Allscripts.com/cdschallenge 
• Janssen, Pfizer and Geoffrey Beene Foundation Alzheimer's Challenge: http://www.alzheimerschallenge2012.com/

Fifth, they had a variety of payors, disease management companies and providers talk about "innovative programs".  Health 2.0 blogged on some of these innovators, and here are two that stood out to me:

• The WellPoint "Care More" model focuses on the 15% of patients which account for 75% of costs.  "Extensivists" work with PCPs to provide early and quick intervention (e.g. patients see the Extensivist clinic a few times a year, in addition to the PCP).  This model also uses a host of other providers as well (e.g. home care, social workers, dietitians...) to create a fabulously deep and rich team for these patients.
• ChenMed is a provider group which focuses only on complex elderly patients.  Their mantra is "Coordination, Collaboration, Convenience, Compliance".  They succeed because they limit MDs to just 350-400 patients and build a whole system around these patients.  

So while these are both great programs, they also represent the weaknesses in the conference:

• The majority of presenters focused on Medicare patients - understandable since that is of utmost interest to CMS… but there is much to learn with younger patients too.  Additionally, CMS must realize that poorly controlled younger patients will wind up in their lap eventually!  We have to somehow integrate CMS with the private insurers in some way to keep them both aligned.
• The majority of presenters said they achieved some quality benefits by focusing a high amount of care on the "most complex 15%" of patients.  On one hand, this is great stuff - and important to learn how they did it so it can be replicated.  On the other hand, it should not come as a shock that expensive heavy lifting on those folks improved outcomes… were these innovations or simply sound logic?  Are they reproducible?  And did they cut costs (e.g. what was the ROI)?  

Additionally, I think a key quote of the day came from Aetna's CMO when describing a program they implemented to help patients after a heart attack. He said, "we gave them free meds after an MI, and compliance was still only 49%!"  So whatever we do we better make sure it is "easier" for patients than their current lives... because behavior change is really hard!!!

And one other great quote came from a nurse who was talking as a patient, knowing she was dying from cancer.  She did her research and chose to not try end-stage treatment that would hurt her quality of life and only possibly give her a small amount of extra time.  She reminded us not to "force" care onto everyone, for as long as someone has been educated, "There are no wrong choices, only informed choices."

Finally, how about some more IT Innovations?
We heard how IT could help collect, analyze and display data… which could be used to find problem areas or identify high risk patients (e.g. predictive modeling).  We even heard how the Archimedes Model can help predict the outcomes of various interventions.  However, we did not hear how IT innovations could allow for better economies of scale (via automation) and easier spread of improved processes.  My theory is that we use IT to help automate the care for the 85% of patients which are "healthy and stable", so that the high touch care for the complex 15% can continue.  I plan to do my best to support companies that fall into either of these buckets!