Engelberg Center for Health Care Reform

Mission

The Engelberg Center is conducting a range of projects that support comprehensive health care reform. These projects and partnerships enhance the Center’s ability to implement change at all levels and bring academic and technical expertise to bear on practical solutions to state and national health care challenges.

The Initiative on Value and Innovation in Health Care is the Center’s cornerstone project. The Initiative works to develop data-driven, practical health reforms that promote broad access to high-quality, affordable care with a focus on continuous health care improvement. The projects within the Initiative focus on changes in policy and practice to improve health care through innovation in biomedical science and clinical practice, reforms in health care delivery and realignment of payments and incentives to promote better evidence, better quality and better health care.

Driven by staff with expertise in policy, biomedical science, and clinical practice, projects within the Initiative involve new ideas, analyses, and practical strategies for implementing them. Many of the projects are supported by broad-based collaborations with a wide range of external stakeholders. Putting this all together results in feasible approaches for driving real health care reform to achieve higher quality health care at a lower cost.

(Click to Initiative page)

Initiative on Value and Innovation in Health Care

The Initiative on Value and Innovation in Health Care works to develop data-driven, practical solutions that promote broad access to high-quality, affordable care that keeps getting better. Simply expanding health insurance coverage to promote access, or trying to lower costs by cutting prices or limiting covered services, will not be enough to achieve health care that does much more to improve health, that is affordable, and that keeps getting better by incorporating new clinical breakthroughs and better evidence.

The projects within the Initiative focus on policy and clinical practice change to improve how biomedical innovation and health care delivery really work, driven by staff with expertise in both policy and clinical practice. Putting this all together results in practical ideas for real health care reform and support to implement them to achieve better health and lower costs for each person getting care.

I. Achieving High-Value Health Care

Bending the cost curve in health care spending

Fundamental breakthroughs in biomedical science, improvements in data systems and network capabilities, and continuing innovation in health care delivery is making health care increasingly individualized and prevention-oriented. These person-focused reforms aim to support these changes in care—not as an afterthought or as an addition to our health care financing and regulation, but as the core goal.

By highlighting a clear vision for reforming Medicare, Medicaid, and the broader health care system, the Bending the Curve: A Framework for Person-Centered Health Care Reform report was produced to set the direction and tone for upcoming political action around physician payment rates, cost containment, and other evidence-driven health care reforms. The Bending the Curve project has produced three reports [links to: September 2009, July 2010 and April 2013] that contributed concrete, feasible steps to reduce health care costs and improve value simultaneously.

Better Measurement of Performance in Health Care

The Quality Alliance Steering Committee (QASC) promotes the implementation of meaningful quality measures, which are needed to support a high-quality, affordable, patient-centered health care system. QASC is working with key stakeholders in the public and private sectors to make standardized information about the quality and cost of health care widely available to a broad range of individuals and organizations, including patients, providers, medical facilities, health insurers, federal and state health agencies, and regional collaboratives. To support this effort, we work with a diverse group of health care reform leaders and content experts to support the implementation of better performance measures; enable providers to improve their quality of care; help consumers make informed decisions about their own health care; and facilitate the creation of public policies, payment policies, and consumer incentives that foster better provider performance. [link to QASC site: http://www.healthqualityalliance.org/ ]

Reforming the Health Care Work Force

Team-based care is emerging as an essential component of patient-centered medical homes, accountable care organizations, and other innovative delivery systems. A team of medical professionals is better equipped to provide high quality, comprehensive care across care settings while also ensuring that each team member is practicing to the top of their ability.

Select organizations are now starting to integrate frontline healthcare workers into team-based care models. The use of frontline workers as part of the collaborative care team shows great promise as a way to bend the cost curve, improve the quality and continuity of care, and increase access to care.

In collaboration with the Hitachi Foundation, the Initiative is identifying innovative workforce development programs in a variety of settings and introducing best practices to a critical group of stakeholders representing payers, delivery systems, innovators, and providers. A study team is conducting key stakeholder interviews with leaders of new models of delivery systems (e.g., accountable care organizations, patient-centered medical homes), payers, employers, and renowned national thought leaders. Qualitative and quantitative measures will be used to develop a business case for career ladder programs and workforce development. [links?]

Post-Acute and Long Term Care Payment Reform

The Initiative is engaged in a number of different projects to encourage reforms in the delivery of post- acute and long term care. For example, the Initiative is working to identify and evaluate alternatives to the current skilled nursing facility payment system in a collaborative approach that includes the Centers for Medicare and Medicaid Services (CMS) and relevant stakeholders; the Initiative is working to assist CMS in considering payment options for general acute and long term care hospitals that care for chronically ill populations; the Initiative is working to develop alternative payment models for Medicare Part B therapy services; and, the Initiative is engaged in a project to develop assessment tools to further the goal of introducing a core set of quality measures for long-term care. [add links]

Long-Term Care Quality Alliance

The Engelberg Center is supporting the Long Term Quality Alliance (LTQA), a coalition of stakeholders concerned with long-term care quality and health care reform. LTQA was formed to respond to the increasing demand for long-term services and support and the expanding field of providers who are delivering that care. LTQA is governed by a broad-based board comprised of 30 of the nation’s leading experts on long-term care related issues. In past years, LTQA has focused on innovative communities and quality measures. The group envisions a shift toward addressing issues of the dual eligible population given the fact that this group is a high-cost, vulnerable population. Additionally, LTQA would like to reposition itself in the industry and has asked the Engelberg Center for greater leadership. The Engelberg Center will sponsor a series of roundtables and opportunities for cross-stakeholder discussion of issues on long-term care. [add link to LTQA: http://www.ltqa.org/ ]

Physician Payment Reform

For more than a decade, the flawed Sustainable Growth Rate formula that is currently used to update the Physician Fee Schedule in Medicare has threatened access to care and caused uncertainty among physicians and others who provide services to Medicare beneficiaries. But broad bipartisan support exists for reform. Reflecting the framework developed in our “Bending the Curve” reports and related initiatives, we are supporting the development of proposals to reform physician payment.

The Engelberg Center continues to be a resource to stakeholders and Congressional staff as they work through the issues involved in moving toward meaningful reform of the Medicare Physician Payment system.

Mark McClellan testified before the US Senate Committee on Finance in June 2013 at a hearing entitled “Improving Health Care Quality: The Path Forward.” Kavita Patel testified before the US Senate Budget Committee in July 2013 at a hearing entitled “Containing Health Care Costs: Recent Progress and Remaining Challenges” and before the U.S. House Committee on Energy and Commerce, Subcommittee on Health at a hearing entitled “Using Innovation to Reform Medicare Physician Payment.”

Dr. Richard Merkin Initiative on Payment Reform and Clinical Leadership The Dr. Richard Merkin Initiative on Payment Reform and Clinician Leadership is a mission-driven effort to generate clinician-led physician payment and delivery reform and increase the national capacity to provide leadership training to clinicians. Clinician leadership – including doctors, nurses, pharmacists, and other health professionals - is essential for innovative, high-value health care reform, and thus the Merkin Initiative underpins much of our work related to health care delivery reform.

The Merkin Initiative is developing evidence-based and politically feasible payment reform options that are alternatives to the current fee-for-service payment system and recommend a pathway for successfully implementing these reforms. The project also recognizes that clinicians, as frontline decision-makers who directly influence the delivery and quality of care, have an important role in driving payment and related delivery system reforms. Effective implementation of payment and delivery systems that improve care and reduce costs will require clinicians who possess a diverse leadership skill-set that includes organizational management, financing expertise, and operational change leadership. To enhance clinicians’ capacity to lead these efforts, the initiative will also develop strategies and programs aimed at closing the leadership gap.

Clinician Leadership Engagement

Darshak Sanghavi is the Richard Merkin Fellow in Payment Reform and Clinical Leadership at Brookings and he is leading the Center’s efforts to enhance clinician involvement in health care delivery system and payment reform through development of a physician-lead vision for payment reform. In addition to developing options for payment strategies and delivery reform, based on leadership from clinical experts, Dr. Sanghavi is developing practical programs to support physician leadership through innovative education initiatives and developing communications strategies for the broader clinical community to support these goals. [link to Darshak’s work]

Public Health and Health Care Reform

Reforms in health care to increase value and improve population health must recognize that the most important determinants of population health involve individual behavioral choices, social factors, and environmental influences that have traditionally been viewed as beyond the realm of health care reform. However, the person-focused reforms supported by the Initiative are increasingly showing how a reformed health care system can do more to support better population health.

Improving Population Health. As the implementation of the Affordable Care Act (ACA) accelerates with many initiatives currently underway to address improving health care access and quality in the United States, the Engelberg Center for Health Care Reform has developed a partnership with the Centers for Disease Control and Prevention (CDC) to strengthen the intersection of health care and population health. This partnership will dedicate a CDC-appointed Fellow to work on a project in conjunction with Brookings. Projects may include advancing population health management in emerging health care systems such as accountable care organizations (ACOs) through financing strategies and shared measures between public health and health care settings or working with communities to evaluate the use of community health needs assessments (CHNAs) and designing an implementation plan to address the items identified in the assessment. This partnership between Brookings and the CDC seeks to create an institutional program to bridge the gap between population health and the health care system to synergize the efforts in both fields for greater benefit and improved health and health care outcomes.

Better evidence for preventing and reducing obesity. The prevalence, health consequences, and cost of obesity in the United States are well-documented. The Centers for Disease Control and Prevention (CDC) reports that more than one-third of U.S. adults are obese and approximately 17 percent of U.S. children are obese—triple the amount since 1980. Many initiatives are currently underway to address this crisis. However, despite multiple and diverse efforts, the complicated, multi-factorial etiology of obesity requires a comprehensive approach to prevention that coordinates health care and public health efforts with broader community and public strategies. The Engelberg Center for Health Care Reform at Brookings will host a one-day conference in November 2013 to discuss the current state of evidence for both obesity prevention and obesity reduction strategies. The event will help identify actionable next steps and replicable strategies to effectively prevent and address obesity in communities across the United States. [Link to agenda]

Robert Wood Johnson Commission to Build a Healthier America. Dr. Mark McClellan and Dr. Alice Rivlin co-chair the Robert Wood Johnson Foundation (RWJF) Commission to Build a Healthier America. The Commission was created in 2008 to identify ways—beyond health care—to improve the health of all Americans. The Commission issued 10 recommendations. Four years after the release of the recommendations, RWJF is reconvening the Commission to provide new guidance in two key areas: early childhood and healthy communities. [http://www.rwjf.org/en/about-rwjf/newsroom/features-and- articles/Commission.html]

II. Accelerating High-Value Biomedical Innovation

While new discoveries in the biomedical sciences have led to many valuable drugs, devices, and other innovations in health care, the innovation process can be very costly, lengthy, and uncertain, leading to delayed or lost opportunities to treat diseases and improve health. Our work on improving biomedical innovation is addressing this, with support from the Irene Diamond Fund and from the Food and Drug Administration.

Tracking Biomedical Innovation

The Initiative each year hosts a State of Biomedical Innovation conference to engage diverse stakeholders from across the medical product development and innovation ecosystem to identify obstacles, strategies, and practical policy solutions to improve innovation of value-producing medical products. Topics have included new regulatory pathways to speed Food and Drug Administration review of promising therapies, metrics capable of providing a more comprehensive assessment of the enterprise’s health, and enhanced public-private partnerships to bolster early science and pre-competitive collaboration between drug sponsors.

Development of better biomedical innovation metrics. This Initiative has brought together experts and stakeholders in biomedical innovation to track progress in biomedical innovation, and develop better metrics to assess how well the biomedical enterprise is doing in delivering innovative medical products to the patients who need them. [Link to State of Biomedical Innovation conference materials, and previous work on biomed innovation] Improving Regulation and Development of Medical Products

In collaboration with Friends of Cancer Research, Brookings convened the collaborations and analyses leading to the Breakthrough Therapy designation in FDA Safety and Innovation Act of 2012. This new designation is an additional tool that FDA can use to engage more with medical product sponsors of promising therapies intended to treat an unmet medical need and provides a clearer pathway for more rapid clinical development and approval. [link to conference materials, NEJM paper, etc]

Under our cooperative agreement with the Center for Drug Evaluation and Research at FDA, we convened an expert workshop to discuss a proposed Limited-Use Approval Pathway for drugs developed in an expedited manner to meet unmet medical needs. The President's Council of Advisors on Science and Technology’s (PCAST) 2012 report, “Propelling Innovation in Drug Discovery, Development, and Evaluation” recommended that Food and Drug Administration develop a new regulatory pathway to accelerate the development and approval of drugs by allowing new treatments to be studied in a narrow subpopulation of high-risk patients with unmet therapeutic needs. Such a pathway could provide more rapid access to innovative medicines to high-risk patients who need them most, as well as, provide market incentive to manufacturers to invest in developing products intended for a narrow subpopulation of patients.

This workshop brought together a diverse group of stakeholders, including clinicians, pharmacists, provider systems, health plans, industry representatives, and patients to discuss the potential benefits and implementation challenges of such a pathway. The conversation covered a variety of topics including possible characteristics of a new pathway to make it effective, and, how stakeholders can cooperate to promote the appropriate use of limited-use products once they enter the market, and additional evidence development and safety surveillance in the postmarket setting. [link to workshop report]

Our annual Conference on Clinical Cancer Research (CCCR), in partnership with the Friends of Cancer Research, provides an important forum for stakeholders in the research community, patient advocacy organizations, government agencies, and industry to tackle important scientific and regulatory opportunities for innovation in cancer therapy. Convened annually since 2008, this day-long conference tackles pressing scientific and regulatory challenges and opportunities for innovations in cancer therapy. [link to past results and upcoming agenda]

Brookings Council on Antibacterial Drug Development (BCADD) is intended to be a forum for thought leaders to identify actionable next steps to promote antibacterial drug development and seek expanded stakeholder engagement. As the prevalence of drug-resistant bacteria continues to rise, there is a pressing need for new drugs to combat infections by these organisms. However, research and development in this area has slowed, creating a public health concern that we lack the drugs necessary to treat multi-drug resistant infections. Challenges to promoting antibacterial drug development may be scientific, methodological, regulatory, or economic in nature.

Under our cooperative agreement with the FDA, BCADD Project activities are designed to explore collaborative, transparent, and innovative next steps that involve a wide range of stakeholders including government, industry, the clinical community, and the public. While there are many issues that affect this field, BCADD activities have primarily focused on potential improvements in clinical trial design and implementation; FDA’s risk- benefit framework; the role of incentives in drug discovery; and the development of reimbursement models that could support both stewardship and expanded development for antibacterial drug products.

Developing Better Evidence on Medical Products and Care

The Initiative collaborates with public and private organizations to improve the science of determining the safety and effectiveness of medical products and services both before and after they reach the market. The Initiative is also leading collaborative efforts to find better ways to promote the effective use of medical treatments that are targeted to particular kinds of patients. The Initiative is supporting the implementation of the Sentinel Initiative [http://www.fda.gov/Safety/FDAsSentinelInitiative/default.ht],, an FDA system that established a vision and objectives for an active surveillance system while maintaining the privacy and security of patients’ protected health information. In less than four years FDA has established the ability to query the electronic health data of over 126 million Americans to assess medical product safety through its Mini- Sentinel pilot. Through a cooperative agreement with FDA initiated in October 2009, the Engelberg Center serves as a neutral convener and brings together broad groups of stakeholders and experts to solicit feedback, ideas, and foster participation in FDA’s Sentinel Initiative.

Similarly, the Initiative is supporting new steps to monitor the safety of medical devices through the FDA Medical Device Epidemiology Network http://www.accessdata.fda.gov/FDATrack/track- proj?program=cdrh&id=CDRH-OSB-MDEpiNet ]. The network would help identify patient outcomes associated with the use of medical devices through the development of a standardized identification system for specific devices. Such a system would increase understanding of any safety issues, initiate efficient communications to providers and patients who might be affected by a device recall, and conduct a range of other activities that rely on more specific information. Congress has directed the FDA to create a unique device identification (UDI) system that would enable tracking and identification of medical devices across the medical device lifecycle (i.e., from production through use in clinical practice). We are identifying and addressing the most pressing opportunities and challenges in achieving successful UDI implementation and encouraging its broad adoption and subsequent use by manufacturers, distributors, payers, providers, and other stakeholders with important roles throughout the medical device lifecycle.

Brookings has assembled a work group of expert stakeholders with interests that span the medical device lifecycle, convened a series of expert workshops to explore issues and strategies that could benefit from more in-depth consideration, and held webinars to engage with broader audiences around the value of UDI implementation. Brookings will use the information gathered from these activities to begin developing a roadmap for successful UDI implementation. This roadmap will convey the value of UDI implementation, help relevant stakeholders address key challenges, and serve as a foundation for policies supporting UDI adoption [links]

III. The Accountable Care Organization (ACO) Learning Network

The Brookings Accountable Care Organization (ACO) Learning Network, supported by Dartmouth, is a member-driven network that supports providers and organizations working with them in implementing accountable care effectively. Brookings and Dartmouth have been working together since 2007, developing focused collaborations to solve practical problems and work groups to address key issues, including risk contracting, performance measures, population health and Health Information Exchanges. The Learning Network website also acts as a resource to track ACO trends and a communication vehicle to share questions, updates and innovations.

The network consists of leading payers, providers, trade associations, and industry representatives all committed to fostering accountable care. Through a member-built core curriculum of topical learning webinars, a series of Brookings scholar-led implementation workgroups, and facilitated collaboration and networking, Learning Network members are leading the way in finding and disseminating key insights and intelligence that is simultaneously improving the overall delivery of care for patients and reducing the total cost of care across the continuum.

The ACO Learning Network also sponsors a major annual summit, the leading opportunity for experts and practitioners to meet to address key issues in accountable-care implementation. [link]

IV. Activities to Support High-Value Health Care Reform

As the open enrollment for the new health insurance marketplace approaches, the Initiative on Value and Innovation in Health Care has hosted different events to convene leading stakeholders from the federal government, the states, and the private sector to discuss the current status and next steps for effective implementation of state and federal health exchanges. As CMS works to advance the diverse processes for successful implementation, Fellows in the Initiative have described how the Initiative’s activities and lessons from their past experiences in implementing Medicare Part D can be applied to the implementation of the new health insurance marketplaces. In June 2013—senior officials from the Centers of Medicare & Medicaid—provided an overview and update on health insurance marketplace implementation including outreach, education, and system requirements for coordinating data flows. [links to blogs etc, particularly those tied to quality and value]

A range of other projects have contributed to the goal of high-value health care. For example, the Initiative worked with seven academic medical centers (AMCs). AMCs educate and train new clinicians across the medical continuum, are the bedrocks of medical research projects, and disproportionately act as the primary health provider for socioeconomically disadvantaged patient populations who are often uninsured or rely on public assistance. Given these additional challenges, and the importance of the academic medical center in medicine, we have assisted this group of AMCs through a targeted series of meetings and webinars that focus on critical AMC challenges and possible solutions. The results of this work can help Brookings and AMCs across the country define the future of the AMC in the era of health reform and help AMCs continue to be leaders in the delivery of high quality, high value, patient-centered care.

[also include any links here to other notable past projects related to delivery transformation]

Brookings is also taking key insights and lessons from member activities and interactions and using the information to help educate key policy makers on health reform implementation. [links to comments on regulations etc]