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Berwick on health care: ‘We have a wealth of good ideas, but they still need …


Donald Berwick, right, administrator of the Centers for Medicare and Medicaid Services.
(Ed Andrieski – AP)

Our health-care system is facing down a massive doctor shortage: By 2015, we will have 63,000 fewer physicians than we need. The Health Care Innovation Challenge, a new grant program Health and Human Services announced this morning, takes a novel approach to solving that problem. It will provide as much as $1 billion in funding for organizations to hire, train and deploy new health-care workers — not doctors, but care coordinators, technicians and community outreach workers that could fill many of the gaps in delivering primary care.

“We’re not very invested in coordination, someone who can see the patient through the system,” says Don Berwick, administrator of the Center for Medicare and Medicaid Services. “Primary care doctors and nurses are obviously a big part of that, but we need a much more enriched workforce to support that.”

Berwick and I spoke Sunday afternoon about the new grant program, how it stands to foster innovation in health care and Republican senators’ new questions about whether funding programs like these is warranted. What follows is a transcript lightly edited for content and length:

Sarah Kliff: Tell me a bit more about this particular grant program, the Health Care Innovation Challenge. What’s the goal with this new $1 billion in funding?

Don Berwick: The country is abuzz with innovators, people in health care coming up with the brightest ideas, achieving innovations that lower costs. I’m seeing examples of this all across the country. So this is a broader funnel, opening the inbox for many innovative organizations and leaders that have an idea to bring into further testing. We’re seeking innovative partners who are going to say, “I have a great idea.” I think we’ll see a range of proposed projects that have very much to do with expanding the workforce.

SK: As you’ve traveled across the country, what kinds of innovations have impressed you the most?

DB: I was in Texas and saw a wonderful program conducted through the community colleges in Dallas, where they were training health-care outreach workers who are dealing with diabetes in a very tough part of the city. They’re working with them on diet and exercise and have seen a remarkable effect. These are people who have a whole new career option. In Alaska, I saw dental technicians getting trained for community outreach. And back in Texas, Baylor Hospital has been doing some very innovative things, using outreach workers to coordinate care from the very first minute.

In all of those cases, one theme is coordination. That’s also a big theme in the Affordable Care Act. Right now, we’re not very invested in that kind of coordination, someone who can see the patient through the system. Primary care doctors and nurses are obviously a big part of that, but we need a much more enriched workforce to support that.

SK: All of these examples still sound pretty localized. What are the challenges in bringing them to scale? How do you grow these to be national approaches to health care?

DB: The big challenge is spread. We have a wealth of good ideas, but they still need to be nurtured. This will be seed money to get innovation to go further. This is venture capital to develop good ideas to scale.

SK: How well do you think this will work? It requires a pretty big paradigm shift by the health-care system, which right now, like you said, doesn’t focus much on coordination.

DB: I am very optimistic. The more I travel, the more I see growing receptivity to this. People know health care has got to transform into something much more. I think times are really different, not absolutely everywhere, but in professional societies there’s a sense of readiness. I think we might be on the verge of better care. And the financial situation adds a new sense of urgency.

SK: This new program is funded by the Center for Medicare and Medicaid Innovation, which the health reform law created to test out new ideas in health-care delivery. Republican senators have recently criticized this fund, questioning whether it’s a worthwhile use of funds in difficult economic times. How would you respond those questions about whether CMMI is a worthwhile investment?

DB: I’m seeing a new level of national readiness and enthusiasm. Here we are, barely 11 months in, and we have major programs on the street. We’re engaging thousands of hospitals, employers and other stakeholders in the Partnership for Patients, the largest and most coordinated effort to reduce medical errors that this country has ever seen. We’ve launched the Pioneer ACOs [Accountable Care Organizations], a bundled payments demonstration. We are working with states on dual-eligibles [patients eligible for Medicare and Medicaid]. That’s a tremendous amount. The public health-care delivery system knows this, and that enthusiasm should be of reassurance to the Senators asking those tough questions.

SK: One thing I’m curious about here is any interplay between the grants you’re rolling out today and our looming physician shortage, where pretty much everyone expects we won’t have enough primary care doctors in coming years. Where do these new kinds of health-care workers you’re trying to fund fit into that?

DB: We know the health-care primary work force is stretched to its limit. We need investments in stronger primary care and the Affordable Care Act does do that, with a boost in payments to primary care providers and to teaching centers. But there’s no single answer. There are many things we can do to expand the primary care pool. That’s part of what we’re doing here.

SK: This is slightly off-topic, but am curious if you’ll answer one question on the final Accountable Care Organization rule that CMS rolled out last month. My sense is it’s gone over much better with the provider community than the initial, proposed rule in March. What have you been hearing?

DB: The reaction has been very positive. Was pleased by the care that the proposed rule was treated with. We received over 1,200 comments and I think our staff really performed really well. It’s much improved because we had so much more advice. The reaction has been favorable and, in some cases, a complete turnaround. I’m getting a lot of calls from health-care organizations and I think we’re going to see this ramp up. Again, it’s part of the same trend towards better, seamless, coordinated care.

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