Mark McClellan, MD, PhD, is a physician and economist who has held some of the nation's most important healthcare jobs. He was administrator of the Centers for Medicare & Medicaid Services from 2004 to 2006, overseeing the launch of Medicare Part D, the prescription drug benefit. From 2002 to 2004, he was commissioner of the Food and Drug Administration. Earlier, McClellan was a member of the Council of Economic Advisers under President Bush and a Treasury official under President Clinton. He also has been an associate professor of economics and medicine at Stanford University.
He has dedicated his career to improving healthcare quality while lowering costs, and now directs the Health Care Innovation and Value Initiative at the Brookings Institution in Washington, D.C. The initiative brings liberals and conservatives together and publishes bipartisan reports on "bending the cost curve in healthcare." He is a featured speaker at Cardinal Health's Retail Business Conference, taking place in Seattle, Aug. 7-10, 2013, and took some time to share some insights about 'person-centered' healthcare reform.
Q: You advocate "person-centered" healthcare reform. What's the difference between person-centered and patient-centered healthcare?
A: We use the term "person-centered" deliberately to make the point that improving health is about more than traditional healthcare. A lot must be done when people are not yet sick, whether that's preventative care or monitoring the risk of future complications. And individuals must be involved, not just providers. This is crucial if we want better health and lower costs.
Q: What does person-centered system mean for traditional healthcare?
A: Payments are based on quality and outcomes. Now, healthcare exists in silos. Physicians get paid fees for service. Hospitals get paid based on DRGs. Skilled nursing is paid separately. This payment system undermines coordination. It doesn't support low-cost, innovative ways to help people get better and stay well. We need to pay in a way that encourages providers to work together to improve overall care and lower cost.
Q: How would it work in the real world?
A: We advocate the creation of Medicare Comprehensive Care (MCC) organizations. Medicare would pay a fixed amount to an MCC to cover a specific group of patients. The MCC would have to meet specific quality and outcome measures but would have considerable freedom in how it coordinates care.
Q: It sounds like the new Accountable Care Organizations (ACO).
A: You could do it through an ACO, but there are many other ways it could be done, too. Perhaps a group of primary care doctors, endocrinology specialists and pharmacists would join together to provide an effective way to manage diabetes. The key is to reimburse in a way that encourages providers to work together and be accountable. Healthcare providers will find the right arrangements if the incentives are aligned properly. Some ACOs, HMOs and health systems are already moving in this direction.
Q: What happens to pharmacists in this new environment?
A: There are lots of roles for pharmacists. Who is better positioned to make a difference in many aspects of basic healthcare -- medication compliance for costly conditions such as diabetes and high blood pressure, for example -- than a pharmacist?
Q: What do you mean by better positioned?
A: Pharmacies are the most prevalent community-based healthcare provider in the country, by far, but are grossly underused for many broadly needed healthcare services. When a doctor's not around, who is available? The neighborhood pharmacy is open. Some pharmacies are already providing basic health services, such as vaccines. Another opportunity is to monitor chronic conditions -- giving blood pressure checks, for example. A nurse practitioner could give strep tests for sore throats at the pharmacy
Q: Why isn't this more common now?
A: The current reimbursement system is a problem. Today, pharmacists often don't get much more than small fees for filling prescriptions. If healthcare was reimbursed under bundled payments, MCCs might pay pharmacies directly as their convenient, low-cost provider. Some of this is already underway in both chain and community pharmacies.
Q: What does this mean for independent community pharmacists?
A: There are lots of opportunities for community pharmacists. Medicaid expansion is important. Oregon has a community-based approach for getting involved in disease management and health promotion. The NCPA (National Community Pharmacist Association) has done great work to help pharmacists handle these kinds of transitions. Community pharmacies are also participating in medication therapy management and other care management programs.
Q: What risks do community pharmacists face?
A: The future is going to be different than the past. No question about that. Owners need to retool pharmacy practices to do more than just filling prescriptions. This will require adapting to changes in contracts, in work flows, and in other aspects of the community pharmacy business model.
Q: Is retooling easier said than done?
A: Definitely, but community pharmacists have some advantages. For example, most laws, regulations and barriers are state-based. States regulate scope of practice, for example. Pharmacists need to look to state government if they want to practice at the top of their skills. States determine if pharmacists have the authority to add services or make minor medication adjustments, for example. Community pharmacists can make a big difference on policy. In addition, community pharmacies have the kind of patient trust and skill in providing medication services that are critical to building more person-focused care that is both better and less costly overall.
Q: Your Brookings project brings conservatives and liberals together to recommend ways to make healthcare more cost effective. How do you get agreement?
A: The big disagreement is philosophical, about the scope of government. Conservatives and liberals disagree on Medicaid expansion, the number of regulations, how generous subsidies should be. But there's a lot of agreement on what must be done to get better care at a lower cost. Common ground exists on changing reimbursement, emphasizing prevention and trying non-traditional things, such as using smart phones and other wireless technologies innovatively.
Q: What do you hope to accomplish in your bipartisan effort?
A: We want our reports to be in the right place when the next round of healthcare occurs. It's going to happen in five or ten years, maybe less, driven by budget pressures or huge gaps in the quality of care. A lot needs to be be done now to prepare.