Practice Management
Content Analysis of CMS Healthcare Innovation Awards From a Physiatric Perspective Matthew J. Smith, MD On June 15, 2012, the Centers for Medicare and Medicaid Services (CMS) announced the 107 recipients of the Healthcare Innovation Awards (HCIA). The 107 awardees received a total of $874,074,900 in funding, with a projected 3-year savings of $1,863,119,104. A word frequency calculator was used to perform a content analysis on the document that announced the projects receiving funding in the 2012 HCIA program. Results were tabulated and categorized to look for prevailing themes and trends. The words generated by the word frequency calculator were grouped into common roots and tabulated to better understand how CMS was rewarding value. Some of the most common words were “manage,” “community,” “coordinate,” “team,” “system” and “integrate.” Additionally, the job positions that the projects propose to create were tabulated and grouped into categories. Physicians, including physiatrists, were not often mentioned, whereas nursing and nonclinical positions were frequently listed. This content analysis showed that the concepts emphasized in the HCIA projects parallel fundamental physiatric principles. The findings may help physiatrists understand how reform is unfolding, prepare for the evolving health care landscape, and recognize future opportunities. PM R 2014;6:1048-1053
INTRODUCTION One of the primary goals of health care reform in the United States is to improve quality while controlling cost. Health economists and policy makers have been trying to shape practice patterns by defining value. Yet, clinicians have not been offered very specific or extensive information as to what these change agents are seeking. Studying the allocation of new government grant money awarded to health care reform projects may demonstrate what criteria are being promoted. The Affordable Care Act created the Center for Medicare and Medicaid Innovation (CMMI) in 2010 for the purpose of testing “innovative payment and service delivery models to reduce program expenditures.while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits” [1]. One of the seven models CMMI is promoting is an initiative to “accelerate the development and testing of new payment and service delivery models.” One of the programs within this initiative is the Health Care Innovation Awards (HCIA). Through the HCIA, the Centers for Medicare and Medicaid Services (CMS) is funding competitive grants to developers of compelling new ideas that deliver health care at lower costs to people enrolled in Medicare, Medicaid, and CHIP. CMS claims that the innovations necessary to improve the health care delivery system may come from local communities and health care leaders from across the entire country. As depicted on its Web site, CMS hopes to partner with these local and regional stakeholders to help accelerate the testing of models. The final batch of the first round of HCIA awards were granted on June 15, 2012 [2]. The June 15, 2012 announcement noted that CMS awarded $874,074,900 to 107 projects aiming to innovate health care by testing new models of care delivery. The estimated cost savings of these proposals over 3 years is $1,863,119,104—an impressive return on investment, if realized. The Institute of Medicine recommends the achievement of quality by optimizing systems and care processes within organizational structures to build interprofessional teams PM&R
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1934-1482/14/$36.00 Printed in U.S.A.
M.J.S. East Greenwich Spine & Sport, Inc, 1351 S County Tr, Suite 100, East Greenwich, RI 02818. Address correspondence to: M.J.S.; e-mail: [email protected] Disclosures outside this publication: consultancy (money to author), Care New England, Clinical advisory board for PICORI grant to Inflexxion (no payments yet); expert testimony (money to author); payment for lectures including service on speakers bureaus (money to author), Kent Hospital, NASS Value Committee (travel and accommodations); payment for development of educational presentations (money to author), Primary Spine Provider Network; travel/accommodations/ meeting expenses unrelated to activities listed (money to author), NASS Injection course, NASS Value Task Force This material was presented in part at the 2013 AAPM&R Annual Assembly in Washington, DC. Submitted for publication March 14, 2014; accepted October 2, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. 6, 1048-1053, November 2014 http://dx.doi.org/10.1016/j.pmrj.2014.10.001
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and establish cultures of collaboration [3,4]. These principles appear to parallel the basic philosophy of physiatric care. To better understand how CMS is rewarding value, a content analysis was undertaken of the HCIA proposals that were awarded funding. Studying the concepts emphasized by the awardees may help physiatrists better understand how reform is unfolding, where opportunities exist, and how to prepare for the evolving health care landscape.
which allowed the generation of a table of words describing the focus of the winning projects (Table 1). A second table was generated by reading the project narratives and manually collating the jobs that the awardees proposed to create. Similar job titles such as “community health workers,” “community care coordinators,” and “community navigators” were then aggregated into categories for comparison (Table 2).
ASSESSMENT OF HCIA RECIPIENTS’ PROPOSALS
DISCUSSION
Word frequency calculators are a form of content analysis used in qualitative research to assess which concepts are emphasized in a document [5]. They were first used for linguistic research with the introduction of computers in the 1950s. As technological advances have made computers more widely available, they are now applied in collaborations between social sciences and humanities (eg, anthropology, sociology, psychology, and philosophy) with natural sciences such as biology, ecology, or medicine. The word frequency calculator used in this project was chosen because it is free, easy to use, and is a Web-based program that does not need to be downloaded or installed (http://www. writewords.org.uk/). The 107 recipients of the HCIA are published in a document on the CMS Web site [2]. A standardized format is used under each project’s title describing the institution, geographical reach, and estimated 3-year cost savings, as well as providing a summary narrative. The narrative includes the purpose of the initiative, the number of people affected, and the number of jobs created. The document of all the awardees’ proposals was run through the word frequency calculator. Results were then consolidated into common roots, such as “nurse, nurses, nursing.” Next, irrelevant words such as “the” and “about” were eliminated,
Various stakeholders are steering health care change in many ways. The HCIA represent how CMS has chosen to distribute nearly 1 billion dollars to study new care delivery and reimbursement systems. For physiatrists to be best prepared to thrive as the practice environment evolves, it is important that they understand the initiatives these change agents are promoting. As such, it was believed to be worthwhile to perform an in-depth analysis of the projects awarded funding under the HCIA. Content analysis is a type of qualitative research using a systematic, replicable technique aiming to produce valid and trustworthy inferences [6]. Many words of text are compressed into a few content categories based on accepted processes of coding. The reliability of this type of analysis depends on the validity of the coding system applied. In other words, different people should be able to categorize the data from the same text in the same way. Whereas simple, reliable processes via use of the word frequency calculator were used to compile the results listed in Table 1, the job position analysis in Table 2 may have methodologic limitations. However, my interpretation of the content analysis is that the value principles being rewarded by CMS are aligned with the basic principles of physiatric practice. The quasi-scientific nature of this analysis serves as a vehicle for commentary to promote discussion of issues relevant to physiatrists.
Table 1. Top 30 relevant words of the 2012 Health Care Innovation Awards Word
No. of Mentions
Word
No. of Mentions
Care/giver/s/ Health/care/ier/LinkNow/partners/spot/y* Patient/s Program/mer/mers/ming/s Serve/d/s/ice/ices/ving Project/s Hospital/ization/s/s Manage/d/ment/r/rs/ing Medical/ly/ation/tions/medicine Improve/d/ment/s/ing Train/ed/er/ers/ing Community/ies/Rxy Save/ings Center/ed/s/central/ized/ic Reduce/ed/s/ing/tion/s
655 546 224 190 187 179 176 163 163 161 152 148 144 140 129
Provide/d/er/ers/s/ing Coordinate/d/ing/ion/or/ors Nurse/s/ing/NP Cost/s/ly Home/bound/less/maker/s Team/ing/s Job/s Clinic/s/al/ally/ian/ians System/atic/s Primary Support/ed/ing/ive Partner/ing/s/ship Integrate/d/ing/ion/ors Prevent/able/ing/ion/ive Educate/ion/al/or/s
116 102 99 93 93 85 83 81 78 75 65 63 59 56 53
*HealthLinkNow (Sacramento, CA) and HealthSpot (Dublin, OH) are telemedicine services companies. y CommunityRx (Chicago, IL) is an in-development electronic database of community health resources.
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Table 2. Jobs being created as a result of the 2012 Health Care Innovation Awards Job Category
Position Created
No.
Project managers/ directors/ administrators
Program coordinator Assistant project manager Strategic initiatives director Project control specialists Health care economist Registered nurse case manager Nurse screener Nurse educator Telehealth registered nurses Nurse practitioners Information technology and data engineer Medical information Technical support Health analyst Learning center technicians Administrative assistant Data entry assistant Operations support workers Customer service representative Home care aides Patient care manager Care team coordinator Health care coordinators Home care coordinator Advanced practice care coordinator Community health navigator Community organizer Community outreach workers Community coordinators Community health advocate Physician leader Medical director Chief medical officer Comprehensive care physician Provider development team leader Asthma educator Wellness educator Health education specialist Clinical diabetes educator Peer wellness coach Research assistant Research analyst Statistician Outcomes analyst Qualitative interviewer Nurse navigator Nurse transition guide Registered nurse care transition coach Health navigator Care transition expert Behavioral coach Mental health worker Social worker Licensed mental health professional Therapist
52
Nurses (including 10 nurse practitioners)
Information technology
Support staff
Care managers
Community
Physicians
Educators
Research assistants
Transition navigators
Behavioral medicine
Table 2. Continued Job Category Pharmacists Business consultants
40
Outreach 35
29
23
22
21
19
16
16
16
Communication
Peer
Paramedics Dental hygienists Physician assistants Physical therapists
Position Created Program consultant Practice improvement advisor Organizational development specialist Lean practice redesign specialist Integration architect Outreach coordinator Outreach worker Outreach director Communication specialist Marketing/communications assistant Communications and public relations manager Peer health worker Peer and family aid Peer leader Peer health coach
No. 10 7
5
5
4
4 2 2 2
Table 1 shows the results of the analysis using the word frequency calculator. The process of grouping common root words is standard and reproducible, and therefore inferences should be valid. However, the interpretation of the various words identified and the concepts they represent may differ depending on the reader’s medical, political and economic interests. As Table 1 shows, some of the top 30 words retained are still very general. However, many of the words do provide insight into the values being rewarded by CMS. In this analysis, words such as “manage,” “community,” “coordinate,” “team,” “system,” and “integrate” reflect the recommendations of the Institute of Medicine previously described. Of note, the only top-30 word that is also a label of a profession is “nurse.” The concepts emphasized by the words in Table 1 parallel physiatric principles. In keeping with the themes of the awardees, physiatrists rely on team collaborations in coordinating care with goals of restoring independent living, minimizing recurrent utilization of medical resources, and preventing complications of chronic conditions. However, the words “rehabilitate” and “rehabilitation” were only used once each in the proposals, and “PM&R” and “physiatry” were not found. This finding likely reflects the nature of the grant process. Although the term “physician/s” was used 35 times, no specific medical specialties were delineated. The funding opportunity announcement encouraged submissions from health delivery systems proposing to integrate services rather than projects dealing with doctors and their patients in isolation. Physiatrists may find opportunities in a reformed health care system where there is increased value placed on principles fundamental to their field.
PM&R
Many of the words noted in this analysis signal ongoing emphasis on the implementation of information technology into practice. The use of information technology to improve care is a common theme in health care reform. Electronic infrastructure is promoted to foster communication and facilitate transitions between venues of care. Technology is proposed as a way to improve accountability by monitoring outcomes and maintaining registries. Physiatrists, along with all practitioners, should prepare their practices to implement these information systems. There may be a role at the physiatric society level for centralized support of a registry architecture and for the promotion of uniform outcome measures. Physiatrists may be able to expand on their inpatient experience with registry data. Ideally, they may be able to extrapolate the use of a uniform, national data standard (the Functional Independence Measure) to account for goal-based care across the discipline. This survey suggests that CMS is valuing such implementation of technology as part of systemized care delivery. The analysis performed of the jobs proposed in the HCIA projects involved manually collating occupational titles into categories. Because this grouping process would be unique to anyone analyzing the text, the reliability of the many inferences may lack inter-rater validity. Nonetheless, the analysis raises important discussion points. The content analysis performed revealed 245 different occupational titles that were mentioned a total of 366 times. The grouping of the jobs with representative examples of the positions in each category is depicted in Table 2. Nursing is the profession with the highest numbers of mentions. A more detailed look at some of the categories suggests that the number of nursing jobs may even be higher. The category “care manager,” for example, is likely to include many candidates with a background in nursing. The number of positions for doctors in this analysis is low compared with nurses and care assistants. Although physiatrists, or any other medical specialists, are not specifically listed, considering the results may illuminate the kinds of job opportunities available as reform proceeds. For example, medical directors will be needed to lead integrated care delivery systems. Physiatrists may consider reinforcing their experience in leading interdisciplinary teams to be attractive candidates for these supervisory roles. Parallels are again seen between the concepts emphasized in the content analysis and the fundamentals of PM&R. Physiatrists coordinate care in interdisciplinary teams and facilitate transitions between levels of care. They work with allied health fields to educate patients on how to avoid complications and maximize function while living with chronic conditions. Choices regarding practice patterns and career decisions may be influenced by the use of this information. These principles may also need to be incorporated into PM&R training programs to prepare graduating physiatrists for future roles. The other notable finding in the job analysis is that a significant amount of resources appears to be going to
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nonclinical positions. Administrators, information technology professionals, and support staff account for more than one third of the jobs proposed. Although the HCIA awardees all propose monetary savings, it is worrisome that the cost of running these complex programs will undermine some of their value. This problem has been seen in Medicare’s demonstration projects, where the reduction in regular Medicare spending achieved did not generate enough savings to offset the additional costs of the programs [7]. In the private sector, Blue Cross Blue Shield of Massachusetts has noted a similar phenomenon with their “Alternative Quality Contract” [8]. The challenge of efficiently administering the care programs awarded funding by the HCIA is highlighted here.
CONCLUSION Health care reform is a vast undertaking, and the HCIA is only one of many programs incentivizing change toward high-value care. Additionally, different readers may interpret the list of words delineated in this article differently. Nonetheless, it is important that physiatrists have an awareness of the changes happening around them. This content analysis illuminates some of the initiatives being rewarded with nearly a billion dollars in financial grants. It is noteworthy that physiatric principles seem to parallel the concepts emphasized by the word frequency calculation and the assessment of the job positions proposed in the projects. By understanding how reform is unfolding, physiatrists can recognize opportunities and prepare for the evolving health care landscape.
ACKNOWLEDGMENT I thank Sara Capobianco for her assistance in collating data.
REFERENCES 1. Centers for Medicare & Medicaid Services. About the CMS Innovation Center. Available at: http://innovation.cms.gov/About/index.html. Accessed October 10, 2014. 2. Centers for Medicare & Medicaid Services. Health Care Innovation Awards Round One project profiles. Available at: http://innovation.cms. gov/Files/x/HCIA-Project-Profiles.pdf. Accessed October 10, 2014. 3. Kohn LT, Corrigan JM, Donaldson MS, eds, for the Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 4. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 5. Tesch R. Qualitative Research: Analysis Types and Software Tools. Oxford, United Kingdom: RoutledgeFalmer Publishers; 1990, 181-195. 6. Wikipedia. Content analysis. Available at: http://en.wikipedia.org/wiki/ Content_analysis. Accessed October 10, 2014. 7. Nelson L. Lessons from Medicare’s Demonstration Projects on Disease Management and Care Coordination: Working Paper 2012-01. Available at: http://www.cbo.gov/publication/42924. Accessed October 10, 2014. 8. Song Z, Safran DG, Landon BE, et al. The ‘Alternative Quality Contract,’ based on a global budget, lowered medical spending and improved quality. Heath Aff (Millwood) 2012;31:1885-1894.
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COMMENTARY FROM CHRISTOPHER STANDAERT, MD In case you have not been paying attention to the discussions on health care reform, it is time to start listening. The current health care delivery system in the United States is largely viewed as both economically untenable and an impediment to high-quality health care. A lot of effort and money are being directed toward identifying more effective ways of delivering care while improving quality and reducing cost. Although it is unclear exactly where this will take us, medical practice will certainly change. Unfortunately, many physicians tend to recoil at the idea of change, particularly if it accompanied by the type of uncertainty with which we are currently faced. With change, however, comes opportunity, and in his article, Dr Smith is informing us that physiatry may be in a relatively fortunate position to benefit from what is happening, particularly if we embrace that which is unique to our field. Dr. Smith’s analysis offers a window into the path being taken by payers, particularly the CMS. Unlike traditional fee-for-service payment models, CMS is interested in models that fundamentally change systems of delivery. In the projects funded through the HCIA, Dr Smith identified the predominance of words like “manage,” “coordinate,” “team,” and “integrate,” which are coupled with “improve,” “save,” and “reduce.” The implication of this language should be clear—the goal is to improve outcomes and reduce cost through integration of multifaceted clinical care. Accountable care organizations, bundled payments, and patientcentered medical homes are all examples of the care models being considered. The push for improving value is seen as both a social and economic imperative. In its 2014 report, the Commonwealth Fund found that the U.S. health care system ranks last in its overall rating system among the 11 industrialized countries studied (as it also did in 2010, 2007, 2006, and 2004), ranking behind most countries in the specific areas of health outcomes, equity, and efficiency. Interestingly, the United States also scores poorly on providing access to information to physicians and in administrative burden, perhaps accounting for some of the issues with efficiency [1]. In 2009, the President’s Council of Economic Advisors released a report outlining the economic implications of continuing with our current fee-for-service system and the benefits of altering this, particularly in ways that would reduce costs. Without change, they estimated that by 2040, health care expenditures would account for 34% of the gross domestic product (GDP) and that 76 million Americans would be uninsured. They also determined that slowing the growth rate of health care spending by 1.5% per year would increase the nation’s overall economic output (GDP), lower unemployment, improve job mobility, and prevent drastic increases in the federal budget deficit. They identified one of the primary flaws in the current system as a set of incentives
that rewards the delivery of services rather than outcomes [2]. This analysis clearly was addressed in the Affordable Care Act, which has set in play a number of mandates, funding structures, and incentives to expand the pool of Americans with health insurance and to re-make the delivery system for care in the United States. Dr Smith’s findings are quite consistent with the intent of the Affordable Care Act and the efforts of payers, most notably CMS. On the home page of the CMS Web site, it states “.coverage is not our only goal. To achieve a high quality health care system, we also aim for better care at lower costs and improved health” [3]. CMS has enacted a number of programs to address this issue, including multiple pilot projects on coordinated, capitated, or bundled care through the CMMI. On an even broader scale, the Affordable Care Act has created an entire infrastructure for encouraging coordinated care. The architects of the Act itself envisioned a number of changes arising in health care delivery as a result of the legislation. These changes include developing care teams to include nonphysician providers, establishing physician-driven care groups to deliver bundled care or to follow incentive-based care emphasizing outcomes and patient satisfaction, and utilizing shared decision making and noneoffice-based care to improve outcomes [4]. These systems all involve a significant degree of coordination, less direct patient care in the office or hospital, and much more extensive use of nonphysician providers. Limited data are available on the real benefits or sustainability of many of the proposed models, and a number of pilot programs are ongoing across the United States. A recent report from the Robert Woods Johnson Foundation provides some preliminary data on a series of pilot programs, albeit more qualitative than quantitative. They have thus far noted that there are a range of mechanisms for deploying coordinated care programs that are generally influenced by characteristics of or legislation governing local care systems. They noted some commonalities, however, including a history of cooperation among providers, payers, and others in the health care system. They emphasize the importance of culture change in the process of developing a new delivery system, something that requires widespread collaboration between providers, payers, hospital systems, state agencies, employers, and patients and their advocates, along with time [5]. What they do not really discuss are the actual patient outcomes and economic implications of these systems, which are clearly crucial determinates of success, ultimately. Although all of this may seem a bit ethereal, the march toward coordinated care systems is clearly affecting practicing physicians on multiple levels. Electronic health records are essential for delivering and monitoring systemsbased care, and their use is rapidly becoming ubiquitous, as
PM&R
is the use of reporting standards and “quality metrics.” The era of private practice medicine is also in rapid decline, while hospital mergers and acquisitions of physician practices are steadily advancing [6,7]. Although these also are necessary structural changes to allow for coordinated care, it is uncertain if they will really result in the cost savings intended, because there are significant concerns about consolidation leading to concentrated market share, reduced competition, and higher prices [6]. The only thing that seems certain in this is that things will change, and that is where the opportunity for physiatry lies. “Manage,” “team,” and “coordinate” can readily describe concepts that are integral to physiatric practice. We are uniquely grounded in multidisciplinary care and have a strong tradition of building teams to address the longitudinal needs of patients with complex conditions. Structured programs for spinal cord injury, traumatic brain injury, and stroke are prime examples. The skill set required to work with multiple other disciplines, build systems for preventative care, and organize delivery of care in multiple settings lends itself quite nicely to coordinated payment models. Our field has developed a relatively large number of providers focusing on spine and musculoskeletal care, many of whom tend to provide episode-based or procedural care. Interestingly, in a system in which outcomes are prioritized over procedures, we may find that our true value in the care of these patients lies in our ability to see complex problems across a system, assess the roles of multiple providers in a patient’s care, and build care around patient-centered goals. In the end, the emphasis of coordinated care systems will be on the maintenance or optimization of health. Providers will have to be the ones to determine the appropriate application of expensive procedural or diagnostic care and may well bear the financial risk for overutilization. In this type of world, the providers who can truly listen to the patient, direct care toward established goals, and optimize
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the utilization of different components of care will be the ones who have the most value to that system. As we look into this coming storm, it is worth considering Dr Smith’s message. Words matter, and there are implications to those associated with health care reform efforts. Achieving integration and value will require leaders who can work within a system and maintain a long-term focus on outcome. As such, I offer 3 more words based on the now popularized quotation from Russell Wilson, quarterback of the Super Bowl Champion Seattle Seahawks: “Why not us?” Why not physiatry?
REFERENCES 1. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: How the U.S. health care system compares internationally, 2014 update. The Commonwealth Fund; June 2014, Available at: http://www. commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror. Accessed October 13, 2014. 2. Executive Office of the President Council of Economic Advisors. The economic case for health care reform. June 2009. Available at: http:// www.whitehouse.gov/assets/documents/CEA_Health_Care_Report.pdf. Accessed October 13, 2014. 3. Centers for Medicare & Medicaid Services. CMS.gov. Available at: http:// cms.hhs.gov/ Accessed October 13, 2014. 4. Kocher R, Emanuel EJ, DeParle NM. The Affordable Care Act and the future of clinical medicine: The opportunities and challenges. Ann Intern Med 2010;153:536-539. 5. Conrad D, Grembowski D, Gibbons C, et al. A report on eight early-stage state and regional projects testing value-based payment. Health Aff (Millwood) 2013;32:998-1006. 6. Christianson JB, Carlin CS, Warrick LH. The dynamics of community health care consolidation: Acquisition of physician practices. Milbank Q 2014;92:542-567. 7. Merritt Hawkins for The Physicians Foundation. Health reform and the decline of private physician practice: A white paper examining the effects of the Patient Protection and Affordable Care Act on physician practices in the United States 2010. Available at: http://www.physiciansfoundation. org/uploads/default/Health_Reform_and_the_Decline_of_Physician_Private_ Practice.pdf. Accessed October 13, 2014.
Content Analysis of CMS Healthcare Innovation Awards From a Physiatric Perspective Matthew J. Smith, MD On June 15, 2012, the Centers for Medicare and Medicaid Services (CMS) announced the 107 recipients of the Healthcare Innovation Awards (HCIA). The 107 awardees received a total of $874,074,900 in funding, with a projected 3-year savings of $1,863,119,104. A word frequency calculator was used to perform a content analysis on the document that announced the projects receiving funding in the 2012 HCIA program. Results were tabulated and categorized to look for prevailing themes and trends. The words generated by the word frequency calculator were grouped into common roots and tabulated to better understand how CMS was rewarding value. Some of the most common words were “manage,” “community,” “coordinate,” “team,” “system” and “integrate.” Additionally, the job positions that the projects propose to create were tabulated and grouped into categories. Physicians, including physiatrists, were not often mentioned, whereas nursing and nonclinical positions were frequently listed. This content analysis showed that the concepts emphasized in the HCIA projects parallel fundamental physiatric principles. The findings may help physiatrists understand how reform is unfolding, prepare for the evolving health care landscape, and recognize future opportunities. PM R 2014;6:1048-1053
INTRODUCTION One of the primary goals of health care reform in the United States is to improve quality while controlling cost. Health economists and policy makers have been trying to shape practice patterns by defining value. Yet, clinicians have not been offered very specific or extensive information as to what these change agents are seeking. Studying the allocation of new government grant money awarded to health care reform projects may demonstrate what criteria are being promoted. The Affordable Care Act created the Center for Medicare and Medicaid Innovation (CMMI) in 2010 for the purpose of testing “innovative payment and service delivery models to reduce program expenditures.while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits” [1]. One of the seven models CMMI is promoting is an initiative to “accelerate the development and testing of new payment and service delivery models.” One of the programs within this initiative is the Health Care Innovation Awards (HCIA). Through the HCIA, the Centers for Medicare and Medicaid Services (CMS) is funding competitive grants to developers of compelling new ideas that deliver health care at lower costs to people enrolled in Medicare, Medicaid, and CHIP. CMS claims that the innovations necessary to improve the health care delivery system may come from local communities and health care leaders from across the entire country. As depicted on its Web site, CMS hopes to partner with these local and regional stakeholders to help accelerate the testing of models. The final batch of the first round of HCIA awards were granted on June 15, 2012 [2]. The June 15, 2012 announcement noted that CMS awarded $874,074,900 to 107 projects aiming to innovate health care by testing new models of care delivery. The estimated cost savings of these proposals over 3 years is $1,863,119,104—an impressive return on investment, if realized. The Institute of Medicine recommends the achievement of quality by optimizing systems and care processes within organizational structures to build interprofessional teams PM&R
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1934-1482/14/$36.00 Printed in U.S.A.
M.J.S. East Greenwich Spine & Sport, Inc, 1351 S County Tr, Suite 100, East Greenwich, RI 02818. Address correspondence to: M.J.S.; e-mail: [email protected] Disclosures outside this publication: consultancy (money to author), Care New England, Clinical advisory board for PICORI grant to Inflexxion (no payments yet); expert testimony (money to author); payment for lectures including service on speakers bureaus (money to author), Kent Hospital, NASS Value Committee (travel and accommodations); payment for development of educational presentations (money to author), Primary Spine Provider Network; travel/accommodations/ meeting expenses unrelated to activities listed (money to author), NASS Injection course, NASS Value Task Force This material was presented in part at the 2013 AAPM&R Annual Assembly in Washington, DC. Submitted for publication March 14, 2014; accepted October 2, 2014.
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. 6, 1048-1053, November 2014 http://dx.doi.org/10.1016/j.pmrj.2014.10.001
PM&R
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and establish cultures of collaboration [3,4]. These principles appear to parallel the basic philosophy of physiatric care. To better understand how CMS is rewarding value, a content analysis was undertaken of the HCIA proposals that were awarded funding. Studying the concepts emphasized by the awardees may help physiatrists better understand how reform is unfolding, where opportunities exist, and how to prepare for the evolving health care landscape.
which allowed the generation of a table of words describing the focus of the winning projects (Table 1). A second table was generated by reading the project narratives and manually collating the jobs that the awardees proposed to create. Similar job titles such as “community health workers,” “community care coordinators,” and “community navigators” were then aggregated into categories for comparison (Table 2).
ASSESSMENT OF HCIA RECIPIENTS’ PROPOSALS
DISCUSSION
Word frequency calculators are a form of content analysis used in qualitative research to assess which concepts are emphasized in a document [5]. They were first used for linguistic research with the introduction of computers in the 1950s. As technological advances have made computers more widely available, they are now applied in collaborations between social sciences and humanities (eg, anthropology, sociology, psychology, and philosophy) with natural sciences such as biology, ecology, or medicine. The word frequency calculator used in this project was chosen because it is free, easy to use, and is a Web-based program that does not need to be downloaded or installed (http://www. writewords.org.uk/). The 107 recipients of the HCIA are published in a document on the CMS Web site [2]. A standardized format is used under each project’s title describing the institution, geographical reach, and estimated 3-year cost savings, as well as providing a summary narrative. The narrative includes the purpose of the initiative, the number of people affected, and the number of jobs created. The document of all the awardees’ proposals was run through the word frequency calculator. Results were then consolidated into common roots, such as “nurse, nurses, nursing.” Next, irrelevant words such as “the” and “about” were eliminated,
Various stakeholders are steering health care change in many ways. The HCIA represent how CMS has chosen to distribute nearly 1 billion dollars to study new care delivery and reimbursement systems. For physiatrists to be best prepared to thrive as the practice environment evolves, it is important that they understand the initiatives these change agents are promoting. As such, it was believed to be worthwhile to perform an in-depth analysis of the projects awarded funding under the HCIA. Content analysis is a type of qualitative research using a systematic, replicable technique aiming to produce valid and trustworthy inferences [6]. Many words of text are compressed into a few content categories based on accepted processes of coding. The reliability of this type of analysis depends on the validity of the coding system applied. In other words, different people should be able to categorize the data from the same text in the same way. Whereas simple, reliable processes via use of the word frequency calculator were used to compile the results listed in Table 1, the job position analysis in Table 2 may have methodologic limitations. However, my interpretation of the content analysis is that the value principles being rewarded by CMS are aligned with the basic principles of physiatric practice. The quasi-scientific nature of this analysis serves as a vehicle for commentary to promote discussion of issues relevant to physiatrists.
Table 1. Top 30 relevant words of the 2012 Health Care Innovation Awards Word
No. of Mentions
Word
No. of Mentions
Care/giver/s/ Health/care/ier/LinkNow/partners/spot/y* Patient/s Program/mer/mers/ming/s Serve/d/s/ice/ices/ving Project/s Hospital/ization/s/s Manage/d/ment/r/rs/ing Medical/ly/ation/tions/medicine Improve/d/ment/s/ing Train/ed/er/ers/ing Community/ies/Rxy Save/ings Center/ed/s/central/ized/ic Reduce/ed/s/ing/tion/s
655 546 224 190 187 179 176 163 163 161 152 148 144 140 129
Provide/d/er/ers/s/ing Coordinate/d/ing/ion/or/ors Nurse/s/ing/NP Cost/s/ly Home/bound/less/maker/s Team/ing/s Job/s Clinic/s/al/ally/ian/ians System/atic/s Primary Support/ed/ing/ive Partner/ing/s/ship Integrate/d/ing/ion/ors Prevent/able/ing/ion/ive Educate/ion/al/or/s
116 102 99 93 93 85 83 81 78 75 65 63 59 56 53
*HealthLinkNow (Sacramento, CA) and HealthSpot (Dublin, OH) are telemedicine services companies. y CommunityRx (Chicago, IL) is an in-development electronic database of community health resources.
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Table 2. Jobs being created as a result of the 2012 Health Care Innovation Awards Job Category
Position Created
No.
Project managers/ directors/ administrators
Program coordinator Assistant project manager Strategic initiatives director Project control specialists Health care economist Registered nurse case manager Nurse screener Nurse educator Telehealth registered nurses Nurse practitioners Information technology and data engineer Medical information Technical support Health analyst Learning center technicians Administrative assistant Data entry assistant Operations support workers Customer service representative Home care aides Patient care manager Care team coordinator Health care coordinators Home care coordinator Advanced practice care coordinator Community health navigator Community organizer Community outreach workers Community coordinators Community health advocate Physician leader Medical director Chief medical officer Comprehensive care physician Provider development team leader Asthma educator Wellness educator Health education specialist Clinical diabetes educator Peer wellness coach Research assistant Research analyst Statistician Outcomes analyst Qualitative interviewer Nurse navigator Nurse transition guide Registered nurse care transition coach Health navigator Care transition expert Behavioral coach Mental health worker Social worker Licensed mental health professional Therapist
52
Nurses (including 10 nurse practitioners)
Information technology
Support staff
Care managers
Community
Physicians
Educators
Research assistants
Transition navigators
Behavioral medicine
Table 2. Continued Job Category Pharmacists Business consultants
40
Outreach 35
29
23
22
21
19
16
16
16
Communication
Peer
Paramedics Dental hygienists Physician assistants Physical therapists
Position Created Program consultant Practice improvement advisor Organizational development specialist Lean practice redesign specialist Integration architect Outreach coordinator Outreach worker Outreach director Communication specialist Marketing/communications assistant Communications and public relations manager Peer health worker Peer and family aid Peer leader Peer health coach
No. 10 7
5
5
4
4 2 2 2
Table 1 shows the results of the analysis using the word frequency calculator. The process of grouping common root words is standard and reproducible, and therefore inferences should be valid. However, the interpretation of the various words identified and the concepts they represent may differ depending on the reader’s medical, political and economic interests. As Table 1 shows, some of the top 30 words retained are still very general. However, many of the words do provide insight into the values being rewarded by CMS. In this analysis, words such as “manage,” “community,” “coordinate,” “team,” “system,” and “integrate” reflect the recommendations of the Institute of Medicine previously described. Of note, the only top-30 word that is also a label of a profession is “nurse.” The concepts emphasized by the words in Table 1 parallel physiatric principles. In keeping with the themes of the awardees, physiatrists rely on team collaborations in coordinating care with goals of restoring independent living, minimizing recurrent utilization of medical resources, and preventing complications of chronic conditions. However, the words “rehabilitate” and “rehabilitation” were only used once each in the proposals, and “PM&R” and “physiatry” were not found. This finding likely reflects the nature of the grant process. Although the term “physician/s” was used 35 times, no specific medical specialties were delineated. The funding opportunity announcement encouraged submissions from health delivery systems proposing to integrate services rather than projects dealing with doctors and their patients in isolation. Physiatrists may find opportunities in a reformed health care system where there is increased value placed on principles fundamental to their field.
PM&R
Many of the words noted in this analysis signal ongoing emphasis on the implementation of information technology into practice. The use of information technology to improve care is a common theme in health care reform. Electronic infrastructure is promoted to foster communication and facilitate transitions between venues of care. Technology is proposed as a way to improve accountability by monitoring outcomes and maintaining registries. Physiatrists, along with all practitioners, should prepare their practices to implement these information systems. There may be a role at the physiatric society level for centralized support of a registry architecture and for the promotion of uniform outcome measures. Physiatrists may be able to expand on their inpatient experience with registry data. Ideally, they may be able to extrapolate the use of a uniform, national data standard (the Functional Independence Measure) to account for goal-based care across the discipline. This survey suggests that CMS is valuing such implementation of technology as part of systemized care delivery. The analysis performed of the jobs proposed in the HCIA projects involved manually collating occupational titles into categories. Because this grouping process would be unique to anyone analyzing the text, the reliability of the many inferences may lack inter-rater validity. Nonetheless, the analysis raises important discussion points. The content analysis performed revealed 245 different occupational titles that were mentioned a total of 366 times. The grouping of the jobs with representative examples of the positions in each category is depicted in Table 2. Nursing is the profession with the highest numbers of mentions. A more detailed look at some of the categories suggests that the number of nursing jobs may even be higher. The category “care manager,” for example, is likely to include many candidates with a background in nursing. The number of positions for doctors in this analysis is low compared with nurses and care assistants. Although physiatrists, or any other medical specialists, are not specifically listed, considering the results may illuminate the kinds of job opportunities available as reform proceeds. For example, medical directors will be needed to lead integrated care delivery systems. Physiatrists may consider reinforcing their experience in leading interdisciplinary teams to be attractive candidates for these supervisory roles. Parallels are again seen between the concepts emphasized in the content analysis and the fundamentals of PM&R. Physiatrists coordinate care in interdisciplinary teams and facilitate transitions between levels of care. They work with allied health fields to educate patients on how to avoid complications and maximize function while living with chronic conditions. Choices regarding practice patterns and career decisions may be influenced by the use of this information. These principles may also need to be incorporated into PM&R training programs to prepare graduating physiatrists for future roles. The other notable finding in the job analysis is that a significant amount of resources appears to be going to
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nonclinical positions. Administrators, information technology professionals, and support staff account for more than one third of the jobs proposed. Although the HCIA awardees all propose monetary savings, it is worrisome that the cost of running these complex programs will undermine some of their value. This problem has been seen in Medicare’s demonstration projects, where the reduction in regular Medicare spending achieved did not generate enough savings to offset the additional costs of the programs [7]. In the private sector, Blue Cross Blue Shield of Massachusetts has noted a similar phenomenon with their “Alternative Quality Contract” [8]. The challenge of efficiently administering the care programs awarded funding by the HCIA is highlighted here.
CONCLUSION Health care reform is a vast undertaking, and the HCIA is only one of many programs incentivizing change toward high-value care. Additionally, different readers may interpret the list of words delineated in this article differently. Nonetheless, it is important that physiatrists have an awareness of the changes happening around them. This content analysis illuminates some of the initiatives being rewarded with nearly a billion dollars in financial grants. It is noteworthy that physiatric principles seem to parallel the concepts emphasized by the word frequency calculation and the assessment of the job positions proposed in the projects. By understanding how reform is unfolding, physiatrists can recognize opportunities and prepare for the evolving health care landscape.
ACKNOWLEDGMENT I thank Sara Capobianco for her assistance in collating data.
REFERENCES 1. Centers for Medicare & Medicaid Services. About the CMS Innovation Center. Available at: http://innovation.cms.gov/About/index.html. Accessed October 10, 2014. 2. Centers for Medicare & Medicaid Services. Health Care Innovation Awards Round One project profiles. Available at: http://innovation.cms. gov/Files/x/HCIA-Project-Profiles.pdf. Accessed October 10, 2014. 3. Kohn LT, Corrigan JM, Donaldson MS, eds, for the Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 4. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 5. Tesch R. Qualitative Research: Analysis Types and Software Tools. Oxford, United Kingdom: RoutledgeFalmer Publishers; 1990, 181-195. 6. Wikipedia. Content analysis. Available at: http://en.wikipedia.org/wiki/ Content_analysis. Accessed October 10, 2014. 7. Nelson L. Lessons from Medicare’s Demonstration Projects on Disease Management and Care Coordination: Working Paper 2012-01. Available at: http://www.cbo.gov/publication/42924. Accessed October 10, 2014. 8. Song Z, Safran DG, Landon BE, et al. The ‘Alternative Quality Contract,’ based on a global budget, lowered medical spending and improved quality. Heath Aff (Millwood) 2012;31:1885-1894.
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COMMENTARY FROM CHRISTOPHER STANDAERT, MD In case you have not been paying attention to the discussions on health care reform, it is time to start listening. The current health care delivery system in the United States is largely viewed as both economically untenable and an impediment to high-quality health care. A lot of effort and money are being directed toward identifying more effective ways of delivering care while improving quality and reducing cost. Although it is unclear exactly where this will take us, medical practice will certainly change. Unfortunately, many physicians tend to recoil at the idea of change, particularly if it accompanied by the type of uncertainty with which we are currently faced. With change, however, comes opportunity, and in his article, Dr Smith is informing us that physiatry may be in a relatively fortunate position to benefit from what is happening, particularly if we embrace that which is unique to our field. Dr. Smith’s analysis offers a window into the path being taken by payers, particularly the CMS. Unlike traditional fee-for-service payment models, CMS is interested in models that fundamentally change systems of delivery. In the projects funded through the HCIA, Dr Smith identified the predominance of words like “manage,” “coordinate,” “team,” and “integrate,” which are coupled with “improve,” “save,” and “reduce.” The implication of this language should be clear—the goal is to improve outcomes and reduce cost through integration of multifaceted clinical care. Accountable care organizations, bundled payments, and patientcentered medical homes are all examples of the care models being considered. The push for improving value is seen as both a social and economic imperative. In its 2014 report, the Commonwealth Fund found that the U.S. health care system ranks last in its overall rating system among the 11 industrialized countries studied (as it also did in 2010, 2007, 2006, and 2004), ranking behind most countries in the specific areas of health outcomes, equity, and efficiency. Interestingly, the United States also scores poorly on providing access to information to physicians and in administrative burden, perhaps accounting for some of the issues with efficiency [1]. In 2009, the President’s Council of Economic Advisors released a report outlining the economic implications of continuing with our current fee-for-service system and the benefits of altering this, particularly in ways that would reduce costs. Without change, they estimated that by 2040, health care expenditures would account for 34% of the gross domestic product (GDP) and that 76 million Americans would be uninsured. They also determined that slowing the growth rate of health care spending by 1.5% per year would increase the nation’s overall economic output (GDP), lower unemployment, improve job mobility, and prevent drastic increases in the federal budget deficit. They identified one of the primary flaws in the current system as a set of incentives
that rewards the delivery of services rather than outcomes [2]. This analysis clearly was addressed in the Affordable Care Act, which has set in play a number of mandates, funding structures, and incentives to expand the pool of Americans with health insurance and to re-make the delivery system for care in the United States. Dr Smith’s findings are quite consistent with the intent of the Affordable Care Act and the efforts of payers, most notably CMS. On the home page of the CMS Web site, it states “.coverage is not our only goal. To achieve a high quality health care system, we also aim for better care at lower costs and improved health” [3]. CMS has enacted a number of programs to address this issue, including multiple pilot projects on coordinated, capitated, or bundled care through the CMMI. On an even broader scale, the Affordable Care Act has created an entire infrastructure for encouraging coordinated care. The architects of the Act itself envisioned a number of changes arising in health care delivery as a result of the legislation. These changes include developing care teams to include nonphysician providers, establishing physician-driven care groups to deliver bundled care or to follow incentive-based care emphasizing outcomes and patient satisfaction, and utilizing shared decision making and noneoffice-based care to improve outcomes [4]. These systems all involve a significant degree of coordination, less direct patient care in the office or hospital, and much more extensive use of nonphysician providers. Limited data are available on the real benefits or sustainability of many of the proposed models, and a number of pilot programs are ongoing across the United States. A recent report from the Robert Woods Johnson Foundation provides some preliminary data on a series of pilot programs, albeit more qualitative than quantitative. They have thus far noted that there are a range of mechanisms for deploying coordinated care programs that are generally influenced by characteristics of or legislation governing local care systems. They noted some commonalities, however, including a history of cooperation among providers, payers, and others in the health care system. They emphasize the importance of culture change in the process of developing a new delivery system, something that requires widespread collaboration between providers, payers, hospital systems, state agencies, employers, and patients and their advocates, along with time [5]. What they do not really discuss are the actual patient outcomes and economic implications of these systems, which are clearly crucial determinates of success, ultimately. Although all of this may seem a bit ethereal, the march toward coordinated care systems is clearly affecting practicing physicians on multiple levels. Electronic health records are essential for delivering and monitoring systemsbased care, and their use is rapidly becoming ubiquitous, as
PM&R
is the use of reporting standards and “quality metrics.” The era of private practice medicine is also in rapid decline, while hospital mergers and acquisitions of physician practices are steadily advancing [6,7]. Although these also are necessary structural changes to allow for coordinated care, it is uncertain if they will really result in the cost savings intended, because there are significant concerns about consolidation leading to concentrated market share, reduced competition, and higher prices [6]. The only thing that seems certain in this is that things will change, and that is where the opportunity for physiatry lies. “Manage,” “team,” and “coordinate” can readily describe concepts that are integral to physiatric practice. We are uniquely grounded in multidisciplinary care and have a strong tradition of building teams to address the longitudinal needs of patients with complex conditions. Structured programs for spinal cord injury, traumatic brain injury, and stroke are prime examples. The skill set required to work with multiple other disciplines, build systems for preventative care, and organize delivery of care in multiple settings lends itself quite nicely to coordinated payment models. Our field has developed a relatively large number of providers focusing on spine and musculoskeletal care, many of whom tend to provide episode-based or procedural care. Interestingly, in a system in which outcomes are prioritized over procedures, we may find that our true value in the care of these patients lies in our ability to see complex problems across a system, assess the roles of multiple providers in a patient’s care, and build care around patient-centered goals. In the end, the emphasis of coordinated care systems will be on the maintenance or optimization of health. Providers will have to be the ones to determine the appropriate application of expensive procedural or diagnostic care and may well bear the financial risk for overutilization. In this type of world, the providers who can truly listen to the patient, direct care toward established goals, and optimize
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the utilization of different components of care will be the ones who have the most value to that system. As we look into this coming storm, it is worth considering Dr Smith’s message. Words matter, and there are implications to those associated with health care reform efforts. Achieving integration and value will require leaders who can work within a system and maintain a long-term focus on outcome. As such, I offer 3 more words based on the now popularized quotation from Russell Wilson, quarterback of the Super Bowl Champion Seattle Seahawks: “Why not us?” Why not physiatry?
REFERENCES 1. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: How the U.S. health care system compares internationally, 2014 update. The Commonwealth Fund; June 2014, Available at: http://www. commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror. Accessed October 13, 2014. 2. Executive Office of the President Council of Economic Advisors. The economic case for health care reform. June 2009. Available at: http:// www.whitehouse.gov/assets/documents/CEA_Health_Care_Report.pdf. Accessed October 13, 2014. 3. Centers for Medicare & Medicaid Services. CMS.gov. Available at: http:// cms.hhs.gov/ Accessed October 13, 2014. 4. Kocher R, Emanuel EJ, DeParle NM. The Affordable Care Act and the future of clinical medicine: The opportunities and challenges. Ann Intern Med 2010;153:536-539. 5. Conrad D, Grembowski D, Gibbons C, et al. A report on eight early-stage state and regional projects testing value-based payment. Health Aff (Millwood) 2013;32:998-1006. 6. Christianson JB, Carlin CS, Warrick LH. The dynamics of community health care consolidation: Acquisition of physician practices. Milbank Q 2014;92:542-567. 7. Merritt Hawkins for The Physicians Foundation. Health reform and the decline of private physician practice: A white paper examining the effects of the Patient Protection and Affordable Care Act on physician practices in the United States 2010. Available at: http://www.physiciansfoundation. org/uploads/default/Health_Reform_and_the_Decline_of_Physician_Private_ Practice.pdf. Accessed October 13, 2014.
