Gil­fil­lan leaves as in­no­va­tions just be­gin­ning

CMS’ idea lab­o­ra­tory is just start­ing to see re­sults as its di­rec­tor steps down

Modern Healthcare - - THE WEEK IN HEALTHCARE - Me­lanie Evans and Jessica Zig­mond

The next chief of the CMS’ idea lab will en­ter the scene just as early re­sults emerge from the young agency’s first ef­forts. Those re­turns will be closely scru­ti­nized for clues to solv­ing the na­tion’s tough­est health pol­icy chal­lenges, as well as picked apart for po­lit­i­cal gain.

But the re­sults are not yet in, which car­ries its own po­lit­i­cal risks. In­deed, the CMS In­no­va­tion Cen­ter con­tin­ues to strug­gle with the ar­du­ous and tense work of how to run pro­grams con­sid­ered among some of the most am­bi­tious and least un­der­stood ini­tia­tives set in mo­tion by the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

“I don’t envy your job,” Sen. Or­rin Hatch (R-Utah) told Dr. Richard Gil­fil­lan, the cen­ter’s di­rec­tor, at a March hear­ing of the Se­nate Fi­nance Com­mit­tee. Gil­fil­lan plans to walk away from it this month.

The op­por­tu­ni­ties and headaches will soon fall to CMS Chief Med­i­cal Of­fi­cer Dr. Pa­trick Con­way, at least tem­po­rar­ily.

Hatch as­sessed “con­fu­sion and clear lack of fo­cus” at the In­no­va­tion Cen­ter and ques­tioned the num­ber of ini­tia­tives and “high­salary” em­ploy­ees car­ry­ing them out. But the agency is gen­er­ally viewed in the in­dus­try as a bas­tion of smart peo­ple do­ing im­por­tant work.

The Af­ford­able Care Act gives the cen­ter $10 bil­lion over 10 years. Its ex­per­i­ments so far in­clude ac­count­able care, bun­dled pay­ments, pri­mary-care case man­age­ment and grants for peo­ple and or­ga­ni­za­tions with promis­ing ideas ($895 mil­lion awarded and up to $1 bil­lion of­fered in a sec­ond round).

Gil­fil­lan’s de­par­ture, an­nounced last week by re­lease of an in­ter­nal CMS memo, was met with sur­prise from in­dus­try ex­ec­u­tives work­ing closely with the In­no­va­tion Cen­ter on its widely watched test of ac­count­able care, the Pi­o­neer ACO model. Some said his exit would risk delays to the pro­gram, which has had a bumpy start. Any re­place­ment will need time to learn the com­plex pro­gram and es­tab­lish the faith Gil­fil­lan earned, which has so far been needed to weather dis­agree­ments, they said.

“I be­lieve he un­der­stood” the con­cerns and chal­lenges of hos­pi­tals and doc­tors work­ing to de­velop and test new pay­ment mod­els, said Dr. Wil­liam Chin, ex­ec­u­tive med­i­cal di­rec­tor of Health­Care Part­ners, a di­vi­sion of DaVita that op­er­ates Pi­o­neer ACOs in Cal­i­for­nia, Ne­vada and Florida. Chin said the in­com­ing chief will face nu­mer­ous un­set­tled is­sues “we’re in the deep throes of try­ing to un­der­stand.” That in­cludes a dis­pute over qual­ity mea­sures that went pub­lic this year.

In Fe­bru­ary, Pi­o­neers pub­licly re­jected pro­posed qual­ity mea­sures that they have to meet in or­der to re­ceive bonuses. The ACO lead­ers asked for an­other year be­fore bonuses are tied to the tar­gets. Fed­eral of­fi­cials said no but agreed to de­velop new per­for­mance tar­gets. Those have not yet been re­leased. Last week, fed­eral of­fi­cials ex­tended a dead­line to July 15 from May 31 for Pi­o­neers to with­draw from the pro­gram.

Gil­fil­lan spoke to hos­pi­tal and in­sur­ance ex­ec­u­tives with more prac­ti­cal knowl­edge and un­der­stand­ing than many within pol­icy cir­cles thanks to his ca­reer with Geisinger Health Sys­tem, said Dr. Ti­mothy Fer­ris, vice pres­i­dent of pop­u­la­tion health man­age­ment for Part­ners Health­Care in Bos­ton.

He fre­quently ac­knowl­edged the chal­lenges providers faced and did not over­look the in­dus­try’s ef­fort or good will. “Rick never made that mis­take,” Fer­ris said. That al­lowed him to build a work­ing re­la­tion­ship, ask for com­pro­mise and re­spond with flex­i­bil­ity, all of which has proved valu­able dur­ing the trial and er­ror of the Pi­o­neer ACO ven­ture. “You have to be able to trust the per­son on the other side of the ta­ble,” he said.

Gil­fil­lan’s de­par­ture did not come as a com­plete sur­prise to ev­ery­one.

“Am I dis­ap­pointed? Yes. Am I sur­prised? No,” said Deirdre Bag­got, a reg­is­tered nurse and vice pres­i­dent of the health­care con­sult­ing firm the Cam­den Group. Bag­got serves as an ex­pert re­viewer in ap­pli­ca­tion re­views for the bun­dled pay­ment ini­tia­tive. “The pace of change at CMS is not what we’re all used to who work on the hos­pi­tal and health plan side,” she added. “And that can be chal­leng­ing.”

Thomas Scully, a se­nior coun­sel at Al­ston & Bird who served as CMS ad­min­is­tra­tor dur­ing Pres­i­dent Ge­orge W. Bush’s first term, said from his ex­pe­ri­ence, lead­ers in th­ese po­si­tions can burn out. Scully also said he doesn’t think Gil­fil­lan’s leav­ing will be too dis­rup­tive for the In­no­va­tion Cen­ter.

“I think he’s a big ideas guy, and a lot of what they’re do­ing now is im­ple­men­ta­tion,” Scully said. “I think it would be worse if he left a year ago.”

Bag­got said she views Gil­fil­lan’s exit as “an enor­mous loss” be­cause he has an un­der­stand­ing of bun­dled pay­ments—which he worked with dur­ing his ten­ure at Geisinger— that few in the health­care in­dus­try pos­sess. “I be­lieve strate­gi­cally they are the best op­tions to achieve the aims of health­care re­form, and I think him leav­ing leaves a real gap in knowl­edge in the area of bun­dled pay­ment.”

Bag­got re­called re­lay­ing con­cerns from bun­dled-pay­ment awardees re­gard­ing data they were ex­pect­ing from the In­no­va­tion Cen­ter. “I got an im­me­di­ate re­sponse on a Fri­day, and on a Mon­day we had a call. On that call, he gave an up­date.”

With 450 sites ready to im­ple­ment bun­dled pay­ments as of Oct. 1, it will be crit­i­cal for the next di­rec­tor to be equally re­spon­sive and ac­ces­si­ble, Bag­got said.

They’ll get both in Con­way—who was named act­ing di­rec­tor—said Mar­i­lyn Yager, a se­nior pol­icy ad­viser at Al­ston & Bird. “He is a bright, con­fi­dent per­son who is will­ing to show in a meet­ing when he’s learn­ing some­thing,” said Yager, a health­care aide to then-Sen. John Kerry (D-Mass.) in the 1980s and a health­care li­ai­son in the Clin­ton ad­min­is­tra­tion.

Nei­ther Gil­fil­lan nor Con­way was avail­able for an in­ter­view last week.

Con­way, a pe­di­a­tri­cian, was named CMS CMO and di­rec­tor of the Cen­ter for Clin­i­cal Stan­dards and Qual­ity in May 2011. “He re­sponds in a way that helps the group or in­di­vid­ual feel like their time is well spent,” Yager said. “I think that’s how govern­ment is sup­posed to run.”

CMS CMO Dr. Pa­trick Con­way, left, will tem­po­rar­ily fill in for de­part­ing In­no­va­tion Cen­ter Di­rec­tor Dr. Richard Gil­fil­lan.

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