I recently attended the second live learning session of the Center for Medicare and Medicaid Innovation (CMMI) Innovation Advisors Program. I joined 72 other advisors in this first cohort, who were selected from a pool of 920 applicants from around the United States. The learning session ended with the viewing of a talk, "Escape Fire." The lecturer was none other than Don Berwick, then president of the Institute for Healthcare Improvement (IHI). The talk was given at the 1999 IHI conference, a decade before Dr. Berwick’s ill-fated appointment as director of the Centers for Medicare and Medicaid Services.
By Dr. Colleen A. Kraft
"Escape Fire" starts with the account of the Mann Gulch fire in Montana in 1949. The fire started when lightning struck the south side of the Gulch and quickly raged out of control. The smoke jumpers followed the rules as they were taught and carried their heavy equipment as they climbed a mountain to avoid the fire. Their leader, in desperation, tried what turned out to be a life-saving innovation – he lit a match and dropped it in the grass in front of where he stood. The new fire, now known as an escape fire, burned the grass in front of him, deprived the fire behind of any substrate, and created an escape path. The leader encouraged the other fire fighters to join him; sadly, none of the others did and all thirteen perished in the fire.
Dr. Berwick used the analogy of the fire to describe our health care system; fragmentation, inconsistency, medical errors, increasing expense, and system of payment that encourages more procedures in lieu of coordinated care. This fire has burned out of control, despite the effort of many dedicated and altruistic professionals who care for patients.
The Center for Medicare and Medicaid Innovation (CMMI) was created by the Patient Protection and Affordable Care Act to build an "escape fire" to save the American health care system. Programs like the Pioneer ACO Model, Health Care Innovation Challenge, Comprehensive Primary Care Initiative, and the Medicaid Emergency Psychiatric Demonstration provide funding to good ideas that could result in efficient and effective new models of care.
The Innovation Advisors Program (IAP) chose the 72 advisors, in part, because of projects submitted in their applications. These projects could become escape fires if tested, found successful, and implemented widely. The IAP learning sessions have provided tools and mentoring on defining project aims, design drivers, quality measures, tests of change, working with leadership, and self-assessment toward project implementation. In between sessions, there are virtual meetings for education and discussion with other advisors about our projects. Monthly reports posted to a Blackboard site and a robust discussion forum allows each advisor to share knowledge and insight on his or her progress as well as others.
My own project asks the question, "What if Medicaid Managed Care hired nurse home visitors to provide in-home, ‘high touch’ care management to pregnant women instead of traditional phone-based case management?" What are the process improvements (for example, how many pregnant women start care in the first trimester, stop smoking during pregnancy, attend all their prenatal visits?)? Can this intervention affect prematurity and low birth weight? Are these moms more likely to establish and sustain a responsive relationship with their infants, preventing toxic stress and promoting brain development? Technical assistance on the design and measures on my project help me take an idea, develop it, measure it, evaluate it.
Other Innovation Advisors projects cover many topics and stages of life, including palliative care, transition from pediatric to adult care, and improvement in hospital processes. The intended outcome is 73 projects that are their own escape fires, projects that can be replicated and adapted nationally to realize the stated three-part aim of "better care, better health, and reduced cost."
Those of us who watched "Escape Fire" felt afterward that our nation wasted a true opportunity, recognizing the truth of the quote that, "a prophet is not without honor, save in his own country." Dr. Berwick’s visionary ideas challenged the sacred cows throughout our traditional, hierarchical health and hospital system, resulting ultimately in the political turmoil over his appointment to CMS. The Innovation Advisors understand the importance of Dr. Berwick’s message as they create future designs for an effective, efficient, patient- and family-centered U.S. health care system.
Dr. Kraft is a professor of pediatrics at the Virginia Tech Carilion School of Medicine and Research Institute, and pediatric program director, Carilion Clinic, both in Roanoke, Va. Dr. Kraft is a primary care pediatrician with Carilion Pediatric Associates. She serves as the chief medical officer for Aetna/MajestaCare, a Carilion Clinic/Virginia Medicaid health plan. Dr. Kraft was recently selected as one of the 73 CMS Innovation Advisors for the Center for Medicare and Medicaid Innovation. Dr. Kraft speaks on the topic of immunizations for Merck. She also is a member of the Pediatric News Editorial Advisory Board.