Category Archives: Health Reform

CMMI Needs Better Interventions, Not Better Research Designs

nytLogoOver the weekend, Gina Kolata, a New York Times health reporter, wrote a piece on the work of the new Center for Medicare and Medicaid Innovation (CMMI) that was created as part of health reform to test potential improvements in health care organization and delivery.

Interestingly, the slant on the story  was on the lack of rigor in the work of CMMI in its failure to use true experimental research designs, those in which participants are randomized to experimental conditions. Using these designs, often referred to as randomized control trials in bio-medicine, yields results that can be interpreted most authoritatively as something about the treatment causing something about the outcome. (Causal inferences.)

Now, I have been critical of the work of CMMI ( See Groundhog Day  and Good Judgment Comes from Experience) and of the Centers for Medicare and Medicaid Services (CMS ) more generally in its efforts to answer critical questions about improving health care in America and particularly for the older adult Medicare beneficiaries for whom they are uniquely responsible.

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No Single, Simple Explanation for High Health Care Costs

As we enter 2014, the topic of health care costs continues to be a major topic of conversation in the media and among policy makers. The topic is complex and can be spun in different ways.

You may have seen the recent news about how growth in health care spending in the United States has remained low for four consecutive years, for which the White House would like to take some credit. Or you may have seen news reports about how Medicaid expansion in Oregon led to higher emergency department use (and therefore higher costs), which is used by some to argue against the Affordable Care Act. The bottom line is that understanding health care costs is a complex task.

Clearly, the issue of out-of-control U.S. health care costs is of crucial importance and has been a serious challenge to increasing funding for other needs, such as improving infrastructure and education. It is also one in which the general public, pundits, and politicians look for simple, single reasons and matching solutions, e.g., obesity/calorie designations on menus; malpractice insurance/tort reform, too much government involvement/more private sector competition, etc.

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Practice Change Leaders Improve Care for Older Adults

PCL_Color_Logo_250Change is hard. It takes leadership to drive change. Robert Jarvik—a former John A. Hartford Foundation grantee and inventor of the artificial heart—once said, “Leaders are visionaries with a poorly developed sense of fear and no concept of the odds against them.”

Today’s successful leaders need that same vision, but they also require a set of skills that go far beyond their clinical training and experience. They need strategies to address policy and payment methodology. They need to engage stakeholders. And they need to measure what matters in terms of cost and quality.

In order to develop this new kind of leadership, people capable of driving health care redesign for vulnerable elders, the Hartford Foundation funds—in partnership with The Atlantic Philanthropies—the Practice Change Leaders Program.

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Medicare readmissions reduction reform is complex, scary—and absolutely necessary

NHPFlogo250Last Friday I was at a session of the National Health Policy Forum (NHPF) in Washington D.C. focused on Medicare’s readmission reduction program  The program, authorized under section 3025 of the Patient Protection and Affordable Care Act (PPACA), is the “stick” to section 3026′s “carrot.”

Section 3026 authorizes the $500 million Community-based Care Transitions Program that will pay partnerships of community-based organizations and hospitals to offer evidence-based, post-discharge services to reduce readmissions. Section 3025, in effect since October 2012, dropped the other shoe and requires the Centers for Medicare and Medicaid Services (CMS) to reduce payment for Medicare services to hospitals whose patients have higher than expected rates of rehospitalization within 30 days of discharge. (For more background, watch this Modern Health interview  with longtime John A. Hartford Foundation grantee Eric Coleman, MD, read this recent Reuters article featuring Coleman, and this post I wrote on Health AGEna in December 2010.

Clearly the audience at the session was very concerned about the program and seemed sure that it should changed, if not abandoned (See my response to a Wall Street Journal op-ed last month.). I see the matter very differently and I’d like to explain why. NHPF Sessions are off the record, so I won’t use any quotes or attribution.

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A Better Way Forward for Dementia Care


Chris Callahan, MD

At the American Geriatrics Society meeting a few weeks ago, I—along with most of the attendees—was spellbound by Dr. Diane Meier‘s Henderson Award lecture  on the issues confronting geriatrics and palliative care and our profound failure to deliver useful care to those with incurable serious illnesses.

One of the pieces of evidence for her arguments that I had somehow missed was a paper by Beeson Scholar alumnus Dr. Chris Callahan and colleagues at Indiana University entitled, “Transitions in Care for Older Adults with and without Dementia.”

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Volk Lecture: Nurses Play Essential Role in Health Care Innovation

Jennie Chin Hansen, chief executive officer of AGS, delivers the Norman and Alicia Volk Lecture in Geriatric Nursing.

Jennie Chin Hansen, chief executive officer of AGS, delivers the Norman and Alicia Volk Lecture in Geriatric Nursing.

Delivering the 5th Annual Norman and Alicia Volk Lecture in Geriatric Nursing, Jennie Chin Hansen, RN, MS, the chief executive officer of the American Geriatrics Society (AGS), eloquently challenged her audience to renew their efforts to ensure that older adults receive better care in hospitals, in their communities, and at home.

A crowd of more than 300 nursing students, faculty, and guests attended the recent lecture at New York University’s College of Nursing. The topic was “Health Care Today and Tomorrow: How Can We Make a Difference?”

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Attack on Medicare’s Hospital Readmissions Penalty Program Is Off-Base

There is a yawning chasm between the health care system we want and what we have. Crossing that gorge will be a messy and inconvenient process—but necessary.

There is a yawning chasm between the health care system we want and what we have. Crossing that gorge will be a messy and inconvenient process—but necessary.

While many of us in the geriatrics community were wending our ways home from the 2013 American Geriatrics Society conference in Dallas with dreams of improved care for older adults dancing in our heads, respected health services researchers Stephen Soumerai and Ross Koppel published a Wall Street Journal opinion piece with a stinging attack on Medicare’s new hospital readmissions penalty program.

We’ve talked about the need for healthy policy debates on readmissions policies before, and as a funder of the work of Eric Coleman, Mary Naylor, and the Society of Hospital Medicine’s Project BOOST to reduce hospital readmissions for older adults, I’d like to continue the discourse by responding to the major points made by Drs. Soumerai and Koppel.

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Navigating the Road to Integrated Care for ‘Duals’

CMS300Recently, I had the privilege of attending a roundtable discussion to learn more about the work underway to develop integrated care plans for those who are dually eligible beneficiaries of Medicare and Medicaid, often referred to as “duals.”

The nearly 9 million people in this group are among the most vulnerable in our society: To qualify, they typically combine poverty, age, and disability. The John A. Hartford Foundation was proud to co-sponsor the meeting in partnership with The SCAN Foundation, a long-time ally in health and aging. Attended by a broad range of stakeholders, the event was hosted by the Alliance for Health Reform, the non-partisan, non-profit group that serves to provide unbiased information to senior Congressional staffers, consumers, health advocates, the press, and the general public.

A core issue facing duals is the financial misalignment between Medicare and Medicaid. This has been a longstanding impediment to coordinated care for Duals. As Chris Langston wrote in an earlier blog post:

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Announcing the Practice Change Leaders

Over the weekend I was at a meeting where Bruce Vladeck, former Centers for Medicare and Medicaid Services administrator (back when the agency was known as The Health Care Financing Administration), said something that really resonated with me. Commenting on the “disconnect” between the potential of geriatrics as a field and the urgent needs of older adults, he said that efforts to “geriatricize” medical education will be insufficient. “Young physicians will know more geriatrics than ever, but it will be drowned out in all the other ‘noise’ surrounding their practice. You can’t bridge the disconnect by reinventing doctors. You have to change systems.

I couldn’t agree more and our new strategic plan focuses on bridging just this disconnect by bringing geriatric expertise to bear on critical leverage points in health care. So, I am very proud to announce the first cohort of the Practice Change Leaders, our newest effort to drive systems change by building on the capabilities of geriatrics experts and alumni of Foundation programs. The list of scholars and their projects is at the bottom of this post.

The Practice Change Leaders for Aging and Health program grows out of the success of the Practice Change Fellows (PCF) program which has offered advanced leadership and systems change training to 40 geriatric health care professionals since its inception in 2007. In this next generation program, the leadership (Eric A. Coleman, MD, and Nancy Whitelaw, PhD) and mentors from the PCF will work with alumni of the federal Innovation Advisors Program, a special leadership program sponsored by the Center for Medicare and Medicaid Innovation to help advance delivery system reform to meet the needs of older adults.

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