By John A. Kohler, Sr., MD
I recently had the pleasure and privilege of spending the day with the folks at the Center for Medicare & Medicaid Innovation (CMMI) in Baltimore. My visit stemmed from an invitation from the center’s director and current Principal Deputy Administrator of the Centers for Medicare & Medicaid Services (CMS), Dr. Patrick Conway. As a young physician at the dawn of my career, the visit was both fact-finding mission and career building. My story of how a neonatology fellow from Duke University found his way to the bowels of the government medical system is, I hope, both interesting and informative.
It all began when I started fellowship with the hair-brained idea that my academic interest as a physician-in-training was located at the intersection of policy, business, and medicine. For me, the current environment of health care reform and the seemingly overnight transformation of health care from fee-for-service to a pay-for-quality system are exciting. I have pursued projects within fellowship that have examined the effects of Medicaid policy change on neonatal reimbursement. After consoling myself following the realization that neonatal reimbursement is so sorrowful, I began to delve deeper into the mystery that is government financed health care. Of course this rabbit hole lead to further discoveries and inevitably, more questions. My ignorance about the exceedingly complicated federal programs that pay a large portion of pediatric care (Medicaid) became increasingly more vast and embarrassing. I would love to blame a lack of education during my formative years (medical school and residency) for my unawareness but I was actually granted some basic instruction on these matters.
During my residency, I was briefed on these programs and the intricate web of child health financing by Dr. Bryan Fine at The Children’s Hospital of The King’s Daughters in Norfolk, Virginia. He gave lectures as part of the Pediatric Health Leadership Certificate Program that was integrated into Pediatric training at my residency institution. It was just the tip of the iceberg. The programs, with the additions and subtractions of the Affordable Care Act (ACA), were just too complex to acquire a firm understanding of the mechanisms at play. To address this lack of training, I, like most of my self-directed physician colleagues, attempted to dispel my own ignorance and reach out for help. I remembered that I was lucky enough to attend a grand rounds presentation during residency given by Dr. Conway. I reached out to my former policy mentor, Dr. Fine, who put me in touch with Dr. Conway. A brief email explaining my interests was met with open arms and an eager invitation from the Director to visit him and his team at the hub of innovative change.
I was unsure of what to expect at the CMMI once I arrived. The road in Baltimore that led to the CMMI building also housed a very imposing FBI building that seemed to be guarding the area. I later found out that the vast majority of the federal budget travels through this area of Baltimore. I went through the now common security checkpoint upon entering the government section of the building and was shocked by what I saw. I was greeted by friendly faces and a bright and open workplace. Glass-walled cubicles filled a space where innovation and brainstorming were evident to any passerby. I was surprised by both the feel of the place (which stood in stark contrast to the DMV-type government building I was expecting) and the people, who were energetic and friendly. My day was filled with meetings with very intelligent and passionate individuals who all seemed to want to work at this place. They all seemed to believe they were working at the forefront of the future of medicine. There was a tangible and palpable energy that seemed to drive the place.
The CMMI is unique in its funding and setup. It was created by Section 3021 of the Patient Protection and Affordable Care Act (ACA). Legally, it exists under Section 1115A of the Social Security Act and it has been tasked with testing models that literally seek to transform the face of Medicare, Medicaid, and the health care system overall. As a person generally skeptical of large government bureaucracies and a firm believer in the untapped opportunities for innovation across our federal system, I was amazed that this place appeared to be where government was best working. The personnel of the CMMI have been tasked with testing different concepts on small scales so that they do not have to be evaluated on large, nationwide scales that, if unsuccessful, would cost millions of dollars. It enables states who are eager to try new approaches to costs-saving to become laboratories of health care. If these models prove successful, the CMMI has been tasked within the law to implement the findings on a larger scale. This is a brilliant way to improve the large public payer systems while acquiring actual data to drive change instead of politics. As a physician, I am used to the idea of evidence-based medicine driving practice decisions, and I have always wondered why politicians were not also expected to seek evidence for their proposals (evidence-based politics?). The CMMI seems to be providing a way to implement evidence-based decision making on a federal level.
The promise of innovation notwithstanding, I was impressed by CMMI’s budget—$10 billion for 2011-2019. The funds are applied across approximately 90 models in an attempt to find ways to improve quality while reducing costs. There are surprisingly few strings attached to this budget. The staff is allowed to evaluate the models periodically and expand the programs. This includes nationwide expansion if the Secretary of Health and Human Services (HHS) determines they reduce cost or improve quality, and the Chief Actuary of CMS determines that the model would actually do so. While my informed-citizen feelers rise at the prospect of large sums of public money spent with little congressional or administrative oversight, it seems like the best possible method through which to seek answers and to try models that could otherwise find resistance on either side of the aisle. I believe it was created this way to remove politics from determining health care best practices, and it more closely mirrors the process that exists on the physician side of medicine—a hypothesis-driven, results-oriented approach to problem solving. This process removes the burdensome bureaucratic and legislative deliberation process and allows model modification based on real-time results. I am not advocating for the removal of oversight in governmental or even CMS activities—rather, I simply think this is a good mechanism for the CMMI.
In my meetings throughout the day, besides the excitement of working in a place where quality change does indeed seem possible, there was one element commonly cited for why CMMI is so unique and productive. The staff continually stated that the leadership of Dr. Patrick Conway has led to an environment of collaboration and discovery. This opinion seemed to permeate all levels of staff—physicians, economists, business leaders, Public Health Corps leaders, and administrative personnel. I know that I would not have been able to appreciate the work of the CMMI without his help and guidance. He is a passionate public servant who has helped steer this exceptional place.
I am sharing my experience at CMMI because I was pleasantly surprised by what I found there. For me, the experience has been helpful as I continue my own research during fellowship training, and evaluate how I may best contribute to the future of health care. I also share it because I have the sense that not all policy enthusiasts, physicians, or members of the general public are familiar enough with this remarkable institution. While the ACA may not be the perfect fix for an imperfect system, I do believe that the Center for Medicare and Medicaid Innovation is a step in the right direction for a public payer system that seeks to excel in quality while reducing costs.
John A. Kohler, Sr., MD, is a fellow in Neonatal-Perinatal Medicine at Duke University Medical Center.