Berwick Sets Goals for New Center for Medicare and Medicaid Innovation
Amy Lotven, Inside CMS, November 2, 2010
CMS Administrator Don Berwick has set broad goals for the health reform law's new Center for Medicare and Medicaid Innovation and is working closely with the center's director, Richard Gilfillan, to design the center and build partnerships with a range of stakeholder groups. Berwick described the CMMI as the “jewel in the crown” of health reform, saying it has the potential to dramatically improve health care quality, but expected Republican gains in Congress could jeopardize the center's funding.
Getting the center off the ground could become more difficult if Republicans win control of one or both chambers of Congress on Tuesday, sources say. Republicans leaders and candidates have said they will try to deny funding for the health reform implementation effort. Michael O'Grady of O'Grady Policy, LLC, said during a recent American Enterprise Institute forum that the $10 billion set aside for the CMMI could become an easy target, a view echoed by several Republican sources.
Republicans have been upset about pilot programs and other administrative initiatives launched by health reform, and are looking for funding offsets to pay for other priorities, sources note.
Despite the political uncertainties, Berwick and Gilfillan have been moving ahead with their technical and operational planning, including discussions about partnerships and evaluation methods that would be used to get the center started. The spectrum could be wide-ranging and include health plans, doctors, hospitals, nurses, and other stakeholders.
Berwick and Gilfillan said during recent discussions at the Brookings Institution that they have been encouraged by stakeholders' early interest in the center. They indicated a willingness to work with a broad range of industry groups, including insurers, and Gilfillan specifically said he hopes Blue Cross Blue Shield plans, as well as other carriers, will team up with the CMMI. CMS also hopes to work closely with hospitals and other providers.
“The mechanics of of setting up public/private relationships which allow us to finally come together and agree on ... a sensible direction, that's very tough,” Gilfillan said. “But I'm completely optimistic about it, and the will seems enormous right now.”
Berwick and Gilfillan stressed that the innovations supported by the CMMI must also achieve all of the dimensions in Berwick's “Triple Aim” concept: using evidence-based medicine; improving the quality of individual care; and lowering costs. Berwick said the CMMI, if properly structured, could be the “trampoline” for improvements in those areas, and both officials said they're evaluating a range of processes and methods to carry out those goals.
The center hopes to come up with ways to quickly capture data and evaluate outcomes. “We will have metrics with each dimension,” Gilfillan said.
Berwick emphasized that he did not want to preempt good ideas that could come forward in the future, perhaps through collaborations with industry. He spoke broadly about his view of the CMMI and his preliminary thoughts about how to achieve its three goals. The first step, he said, is “entity stratification” or ensuring that best practices become commonplace. For example, medical providers have good evidence on how to virtually eliminate pressure ulcers and certain infections, he said. But, he adds, “What we don’t know is how to make the best (care), the standard.” “That itself is innovation,” he added.
The second level of the stratification that Berwick has been pondering is the promotion of seamless, coordinated care. “When people talk about accountable care organizations, or bundled payments or medical homes or health homes, they're using words that encode the dream of establishing a system that is seamless and coordinated at every level, Berwick said. People want to live the fullest lives in the least possible pain with the least possible dysfunction, and that cannot be done without coordination,” he said.
But he stressed that when it comes to integrated systems, one size does not fit all. Berwick said he does not know how many variations on integrated systems will ultimately emerge, but said he assumes there will be at least a dozen. The challenge is to figure out what it looks like customized to the proper segment of the population, fit into the right context and localized because, he says, “the best innovations will surface from the community.”
Applying those quality improvements at the population-based level could be the most challenging piece of the CMMI's mission, Berwick said. The CMMI should be make a serious investment in that area, he added.
Gilfillan said he is confident that the center's portfolio will be broad enough to affect the total population, but with the understanding that there are some groups where meaningful change is most likely. The CMMI will “hopefully be hearing from people who have proposals to address narrow segments,” he said. They key point is that the solutions touch upon all three dimensions of the triple aim.
Outcomes will be extremely important, and stakeholders can expect lots of attention paid to understanding data that emerges from the center, he said. To that end, CMMI is very interested in the rapid development of evaluation methodologies, he said. “We think probably this is not going to be your father's innovation activity, and it is not going to be your mother's evaluation methodology and we need to learn more about that,” Gilfillan said.
CMMI is also studying ways to help spread innovative ideas, such as through accountable care organizations and bundled systems, so that they can be widely dispersed and evaluated under different contexts, and then, if proven successful, spread even further, he said.
There has been much thinking about how CMMI can accelerate not just the emergence, but also the spread, of new ideas, Gilfillan said. -- Amy Lotven ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )
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