Doctor tries to upend U.S. health system to cut costs

WASHINGTON — If the former Health and Human Services secretary, Kathleen Sebelius, was the poster child for health-care reform pitfalls, then Patrick Conway might be the hidden face of the law's promises.
A pediatrician and top administrator at Cincinnati Children's Hospital Medical Center until 2011, Conway now is leading the federal government's efforts to change the health-care system from one that rewards quantity to one that rewards quality.
Right now, health care providers generally are paid — whether by an insurance company or the government's Medicare or Medicaid programs — for each procedure, each test, and each patient appointment they conduct. Health-care experts have long argued this provides a perverse incentive for providers because they have no rewards for keeping patients healthy and out of the hospital or the doctor's office.
To help flip that equation, the Affordable Care Act created an "Innovation Center," financed to the tune of $10 billion over 10 years and housed at the Centers for Medicare and Medicaid Services, the government agency that administers those two federal health care programs.
The 40-year-old Conway is the centers' innovation chief, along with several other more official titles. His mission is to achieve what health care wonks call the "triple aim": bring down sky-high health care costs while achieving better health outcomes for patients and higher quality of care across the system.
To get there, Conway and other federal health officials are disbursing dozens of grants and financing a bevy of pilot programs across the country in a carrot-and-stick approach to push health-care providers to change the way they do business.
They're testing ways to pay doctors for an entire episode of care — from diagnosis to cure — instead of for each treatment. And they're encouraging the creation of new physician networks with doctors working across specialties and even at different institutions to provide a highly integrated continuum of care for their patients.

Dr. Patrick Conway

Under the Affordable Care Act, the innovation center has the authority to implement such innovative approaches nationwide, as long as they meet certain benchmarks of success. They haven't done so yet, but experts say the center's work could go a long way toward determining the success of the Affordable Care Act and toward charting the future of America's health-care system.
"Everybody knows the system has to move," said Susan Dentzer, a senior health policy adviser at the Robert Wood Johnson Foundation, a philanthropy focused on improving public health. "Payment has to be tied to quality and the outcomes that we want,"
She said the challenges facing Conway are "enormous," but he is well-suited for the task.
"He lives and breathes the triple aim," she said.
That's not an exaggeration. In his office at CMS's Baltimore headquarters, the affable and boyish-looking Conway has a whiteboard with three life goals clearly outlined:

• Be a great husband and father.
• Catalyze the health system to achieve better care, better health and lower cost for all Americans.
• Put patients and families first.
Next to each goal is "a little square that I never check, which signifies that I'm always working on it," says the father of three children, ages 2, 4, and 6. "At the core, I love driving improvement of systems that help people."
That love is what took him to Cincinnati Children's Hospital, which has a long history of quality improvement.
A native of Texas, Conway moved to Cincinnati in 2007 with his wife, a nurse he met in Boston while he was finishing his pediatric residency at Harvard Medical School's Children's Hospital.

Conway was quickly appointed head of hospital medicine at Cincinnati Children's, where he pioneered efforts to involve parents in decision-making about different antibiotic treatments for children with bone infections.
"By engaging parents in the decision-making, he was able to very successfully implement this in newly diagnosed patients," said Uma Kotagal, senior vice president for quality, safety and transformation at the hospital. "It made a big difference" in patient satisfaction and outcomes.
When Conway was offered the chance to do that kind of work on a national scale, it was a no-brainer. After starting as CMS in 2011, he was tapped to lead the innovation center last fall.

"This is by far the most challenging job but also the most rewarding I've had in my life," he said. "Challenging because we are … trying to catalyze positive change in a health care system that represents $2.7 trillion (the level of health care spending) and cares for the entire U.S. population. And rewarding because we are moving national needles in the right direction."
Not everyone is a fan of the federal center.
"Innovation and best practices in health care do not come from federal programs, no matter how well intentioned, but rather from health care providers who are actually seeing and caring for patients," said Rep. Brad Wenstrup, R-Ohio, a podiatrist and vocal critic of the Affordable Care Act.

"That is the fundamental conceit of Obamacare, the notion that the federal bureaucracy can effectively manage care better than doctors and other providers across the country," he said.
Other congressional Republicans have raised questions about whether the innovation center is spending tax dollars effectively. In a recent letter to Health and Human Services Secretary Sylvia Burwell, who replaced Sebelius after the disastrous rollout of the federal health exchanges, three GOP lawmakers said the center's broad scope "raises serious concerns about the potential lack of transparency and accountability."
Supporters say that criticism is off base. And they note that Conway is not some detached federal bureaucrat but rather a practicing pediatrician.
After first joining Centers for Medicare and Medicaid Services, Conway was squeezing in his clinical work at Cincinnati Children's on weekends. But now he does patient care at the children's hospital in Washington, where he treats kids with multiple chronic conditions.

A sign for the Children's National Medical Center in Washington where Dr. Patrick Conway spends his weekends doing patient care.

Dentzer said the fact that Conway still sees patients regularly is one of the reasons he's so effective as a regulator and policymaker.
"He completely understands that all of these programs have to work where the rubber hits the road," she said. "It's got to work at the physician level. It's got to work at the patient level. It's got to succeed in healthy people in communities."
Others noted that Medicare and Medicaid are major spenders in the American health care economy, and to save taxpayer dollars, those programs need to be at the forefront of change.
"Everybody has recognized that we have to achieve better quality for the amount we spend on health care," said Lisa Simpson, a pediatrician and health policy researcher who worked with Conway at Cincinnati Children's. "The challenge for Patrick is really quickly understanding which demonstrations (and) which interventions are the most effective at moving the dial."
For Conway, one example stands out: Last year, the innovation center awarded $42 million to Arkansas for an initiative aimed at strengthening primary care. Under the program, participating doctors are paid a monthly fee for each of their patients instead of being paid per visit.
In a discussion about the program, Conway said one of the doctors told him the program was allowing him to stop "worrying about how many patient visits I can churn through in a given day" and instead to offer individually focused, high-quality care.
"He said, 'This is the first time in my life I've actually been able to do what I want for my patients,' " Conway recounted. "That's the kind of health system we all want."

From USATODAY.COM