New Md. waiver must en­cour­age med­i­cal in­no­va­tion

Baltimore Sun - - COMMENTARY - By John M. Colmers John M. Colmers is a se­nior vice pres­i­dent at Johns Hop­kins Medicine and a mem­ber of the Health Ser­vices Cost Re­view Com­mis­sion; his email is

Nearly three years ago, Mary­land em­barked on a no­ble ex­per­i­ment to si­mul­ta­ne­ously hold down the cost of health care while im­prov­ing qual­ity and the pa­tient ex­pe­ri­ence. Build­ing upon Mary­land’s 40-year his­tory of in­no­va­tion in health care fi­nanc­ing, this new agree­ment with the fed­eral govern­ment has cre­ated a plat­form for hospi­tals to part­ner in new ways with each other, with other providers and with the com­mu­ni­ties they serve.

Although per­for­mance in the first two full years op­er­at­ing un­der this new “waiver” has been pos­i­tive, chal­lenges re­main. As the state and fed­eral gov­ern­ments con­tem­plate the next steps, there are par­tic­u­lar con­cerns fac­ing Mary­land’s aca­demic health sys­tems that should be ad­dressed.

Mary­land has long been a leader in bio­med­i­cal re­search and dis­cov­ery. Our two aca­demic med­i­cal cen­ters are na­tional and in­ter­na­tional pow­er­houses, bring­ing in more than $1 bil­lion in re­search fund­ing an­nu­ally. The Na­tional In­sti­tutes of Health and the ex­plo­sion in pri­vate bio­pharma ac­tiv­ity in Mont­gomery County and in­creas­ingly in Bal­ti­more City are fur­ther tes­ta­ment to Mary­land’s place in this dis­cov­ery ecosys­tem. These in­vest­ments have re­sulted in break­through treat­ments and fun­da­men­tal new un­der­stand­ings of ba­sic phys­i­o­logic pro­cesses. As the state pur­sues the laud­able goals of the new waiver and con­trol­ling the to­tal cost of care, we must be care­ful that the ef­fort is de­signed so as not to dis­rupt progress in bio­med­i­cal dis­cov­ery and in­no­va­tion.

There is no doubt that our health care sys­tem can and must be­come more ef­fi­cient. The new waiver has en­cour­aged hospi­tals to think out­side their walls and to part­ner with other health care providers and the com­mu­ni­ties they serve to pre­vent read­mis­sions, im­prove qual­ity and ul­ti­mately to im­prove the health of the com­mu­nity. Hospi­tal read­mis­sion rates have fallen as have health care as­so­ci­ated com­pli­ca­tions. Pa­tients suf­fer­ing from chronic dis­ease are now more of­ten treated in the com­mu­nity, and pa­tient sat­is­fac­tion has be­gun to show im­prove­ment. Hospi­tals plan to strengthen and ex­pand these part­ner­ships with com­mu­nity providers.

The Global Bud­get Rev­enue sys­tem, a to­tal cap on spend­ing that was im­ple­mented as part of the new waiver, has cre­ated very strong in­cen­tives for hospi­tals to achieve these goals. Un­for­tu­nately, some have sug­gested that these same in­cen­tives make it more dif­fi­cult for clin­i­cian sci­en­tists to ad­vance new cures and ther­a­pies.

Ex­am­ples of these in­no­va­tions in­clude new ap­proaches to car­diac care, such as min­i­mally in­va­sive sur­gi­cal pro­ce­dures that re­pair heart valves with­out re­mov­ing the old dam­aged ones and sur­gi­cally im­planted pumps to help heart fail­ure pa­tients. This dis­cov­ery also ex­tends to what is re­ferred to as pre­ci­sion or in­di­vid­u­al­ized medicine in which physi­cians can more ac­cu­rately di­ag­no­sis and treat dis­eases like can­cer or neu­ro­log­i­cal dis­or­ders tai­lored to ge­netic and other char­ac­ter­is­tics of each pa­tient. In the short run, these types of in­no­va­tions are likely to add costs to the sys­tem, but in the long run, the re­turn will be in lives saved and costs avoided.

These types of ef­fi­cien­cies in­clude Johns Hop­kins’ part­ner­ship with Anne Arun­del Med­i­cal Cen­ter to pro­pose a new car­diac surgery pro­gram where pa­tients al­ready treated there can re­main in a lower-cost set­ting closer to home, cre­at­ing ca­pac­ity at Johns Hop­kins Hospi­tal for the sick­est car­diac pa­tients re­quir­ing more com­plex highly spe­cial­ized care. UMMS has a part­ner­ship with Prince Ge­orge’s Re­gional Med­i­cal Cen­ter that pro­vides sim­i­lar ben­e­fits for pa­tients in that com­mu­nity. This fol­lows the pat­tern of many other crit­i­cal ser­vices that are de­vel­oped and re­fined at aca­demic cen­ters, then ex­panded to other de­liv­ery sites as they are de­ter­mined to be safe, cost­ef­fec­tive and worth­while.

By the end of this year, Mary­land must sub­mit a blueprint to the fed­eral govern­ment for the next phase of the waiver. With­out a doubt, it must in­clude plans to en­hance pa­tient care and cre­ate mech­a­nisms to im­prove care co­or­di­na­tion for Mary­land’s sick­est pa­tients. At the same time, how­ever, it must be de­signed so as to per­mit our aca­demic med­i­cal cen­ters to thrive in the global mar­ket for in­no­va­tion. The state health reg­u­la­tory com­mis­sions — the Health Ser­vices Cost Re­view Com­mis­sion and the Mary­land Health Care Com­mis­sion — and the Mary­land Depart­ment of Health and Men­tal Hy­giene must act wisely in all of these ar­eas to pre­serve what is good about the state’s health sys­tem and at the same time al­low it to in­no­vate and evolve.

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