On October 1, 2013, Healthcare.gov launched in a brilliant display of bureaucratic mismanagement. The first day that the signup was open, six people across the country were able to enroll on the site. For months thereafter, the number of enrollees languished as the Obama administration battled upcoming deadlines and a bloodthirsty Republican House of Representatives. (The numbers have since risen over 7.5 million enrollees, matching the administration’s expectations.) A month after complex language forced a delay to the business mandate of the Affordable Care Act, the House voted to amend the law for the fiftieth time in four years.

Notwithstanding these growing pains, the ACA represents neither the beginning nor the end of the centrality of healthcare policy to the federal entitlements system. On the contrary, the ACA is based on decades of research that has grown exponentially in the past 15 years. More importantly, the passage of such landmark legislation has opened the door for those at the vanguard of healthcare modernization to introduce ideas that would have been unthinkable just a few years ago.

Some of these professionals work directly for or are affiliated with Yale University. Since the passage of the ACA in 2010, a growing slate of Yale doctors, professors, and alumni have used their unique positions to inspire debate and, in many cases, to influence national policy. From Medicare reform to healthcare entrepreneurship, they impact each facet of the current discussion.

After January 1, 2014, nearly all of the most salient parts of the law finally made their debut. As federal implementation of these new programs is scaled down, the reins of reform are in the hands of individuals and teams like those at Yale.

Dr. Harlan Krumholz ’80 and his team at the Center for Outcomes Research and Evaluation (CORE) are working to fill in the details of broad metrics that will help make hospitals more accountable for the care they provide. Dr. Stephen Cha, a former Robert Wood Johnson Clinical Scholar at the Yale School of Medicine, is now the Chief Medical Officer for Medicaid and CHIP. Branford College Master Elizabeth Bradley’s book The Health Care Paradox caused waves by succinctly introducing public health policy into a political discourse that has long been dominated by concerns about medicine instead. Professor Martin Klein’s InnovateHealth initiative takes the same techniques that are being used to encourage entrepreneurship in the tech space and applies them to public health innovation instead.

The Politic sat down to speak with these leaders about their relationship to Yale and an ever-changing healthcare playing field.


Center for Outcomes Research and Evaluation


Hundreds of pages into the ACA, Congress included a provision that creates a new “value-based” payment scheme for hospitals. The model is part of a broader push to realign the incentives of patients, hospitals, and the taxpayers in a system riddled with inefficiency. Though the law ensures that hospitals will be evaluated under certain predetermined metrics, and those metrics will be pegged to relevant incentives, it leaves many of the program’s details at the discretion of the Secretary of Health and Human Services. For this reason, the Department of HHS chose to delegate certain critical research to outside bodies like CORE.

Through the CORE Quality Measurement project, Krumholz and his team focus on patient-centered care. “We produce the federal outcomes performance measures that are publicly reported on the web and have been incorporated into incentive packages in the Affordable Care Act,” Krumholz said. “For example, hospitals in the country are now focusing intently on improving the recovery of patients after they leave the hospital because we’ve developed a measure that assesses the likelihood of readmission after going home.” This measure was developed through “Hospitalomics,” a separate but related project.

The extent to which CORE’s research influences public policy sets it apart from the endeavors of most academics and policy researchers. Congressional leaders routinely work with experts and think tanks to devise legislative proposals, but Krumholz is operating under the auspices of the executive branch, which has far more leeway in implementing policy after the passage of a massive bill like the ACA.

According to Krumholz, the advice of CORE falls under the “rule-making” authority of the executive branch. “Rule-making turns out to be a very important, kind of under-the-radar mechanism by which the law gets implemented and it has lots of influence.” As thousands of academic papers each year fall through the cracks, CORE’s research goes straight to policy-makers. And this research is not just limited to Medicare; CORE also secures contracts from national medical foundations and the FDA.

For Krumholz, the most rewarding part of his time at CORE has been “seeing the work you do translated into action that you think is going to help individual patients.” He added, “If you can’t measure it, you can’t manage it. If it’s invisible, it’s easy to ignore.”


Medicaid and CHIP


In 1965, President Lyndon Johnson established Medicaid as a staple of his Great Society dream, and 32 years later President Bill Clinton created the Children’s Health Insurance Program (CHIP). Both programs are means-tested and cover a combined 68 million Americans. Unlike Medicare, however, they are not exclusively federal programs. Rather, the states execute Medicaid in consultation with the federal government, which ultimately foots the bill.

Standing between federal regulations on Medicaid and state actors is the Center on Medicaid and CHIP Services (CMS). While the load borne by CMS had previously been significant, the passage of the ACA increased its responsibilities to include the coordinated implementation of relatively untested models like health homes. Health homes, like a handful of provisions in the ACA, have long been staple example for healthcare reformers, but the ACA is finally making an attempt to turn them mainstream.

Dr. Stephen Cha, who earned a masters degree in health sciences research at Yale, is the Chief Medical Officer for CMS, where his concerns include these new programs and more. Generally speaking, Cha’s office looks for “low-hanging fruits,” or policies that are easier to assess but can provide outsized benefits through their impact on the current medical incentive structure. These policies can be negotiated using two strategies. On the one hand, there is payment reform. “How do we make sure we put the carrots in the right places and the sticks in the right places with respect to incentives?” Cha asked. Alternatively, CMS can manipulate delivery reform, or “what you actually need to do to change the way care is delivered to ensure that you’re delivering on your promises.” Though these methods are distinct, Cha argued that they are best used in tandem.

For example, many physicians once believed that a woman who has been pregnant for 38 weeks could have an induced birth or a Caesarean section without any detriment to the child. More recent research, however, shows that even one additional week in the womb can have major effects on the child. CMS and its partners tackled this issue through an initiative called Strong Start. Through a combination of payment and delivery reform, CMS-coordinated efforts across the nation “may have potentially halved” the number of early-term deliveries.

But Cha’s work does not stop at medical reform. He cited the efficiency of tobacco quitlines that “are traditionally considered a public health lever” as another opportunity that CMS seized upon to improve healthcare. Cha said the goal of CMS is “creating a seamless set of services that are improving care for our beneficiaries.”

The majority of authority exercised by CMS stems from simple communications with state partners. One mind-blowing statistic in policy circles is that one percent of beneficiaries utilize 25 percent of resources. A recent movement among some clinics has been “hot spotting,” or tracking these super utilizers to cut costs where they are highest. After collecting a significant amount of data on successful hot spot clinics, CMS released a report profiling these groups as models for the nation. States took note and acted on their own initiative to embrace the best practices of the report.

“We do not have a mandate from the federal government,” said Cha, “nor would we want to, because to a large degree each state is different.” This is a contentious point for critics who cite encroaching federal power as a reason for increased inefficiency. Indeed, a close look at CMS suggests a contrary position is true. It may be that Medicaid and CHIP are inherently bureaucratic but their fixation with best practices produces enormous good.

“I’m in a unique spot in being able to think about how we can leverage forward enormous federal and state investments to reshape our health systems for our most vulnerable populations,” concluded Cha. “And it really is rewarding working with such fantastic people across the board and across the nation.”


The American Healthcare Paradox


In a healthcare system long dominated by pushes for new medical standards and procedures, the ACA represented a revolutionary pivot toward public health. As Cha said, “There are probably more pages in the ACA in the public health section than there are in the core insurance changes.”

Elizabeth Bradley is a professor of public health, director of the Yale Global Health Initiative, and co-author of the book The American Health Care Paradox, which was published in November 2013. In just the last few months, however, the insights contained in the book have generated considerable attention. Bradley sounded cautiously optimistic about the growing importance of public health in the national discussion, citing several interviews and an invitation to address the Senate after the publication of her book.

Bradley’s optimism is well-founded. Unlike Cha and Krumholz, Bradley is not a physician, but her management background imparts a pragmatic tone to her critique of the American welfare state. “Some people are mooching [on welfare], but why are we letting them mooch? Isn’t there a way to make it so you have to meet certain criteria and can’t mooch?” The answer is yes, argued Bradley. “We can shore up our public systems of housing, of education, so that there is greater management of them and you have accountability.”

Reforming these distinctly non-medical fields can lead to huge efficiency gains of the sort Krumholz, Cha and the majority of Congress want to see. Careful spending on select fields is a public health solution that strikes at the heart of the ACA’s goals.

Bradley cited the two-year Congressional election cycle as one structural issue that prevents politicians from committing to long-term change. Another problem is policymakers’ myopic evaluation of public health services. By classifying education, public housing, and healthcare as independent programs without any impact on one another, inefficacy abounds.

“In the ACA, we have these accountable care organizations (ACOs). Those ACOs get paid more or less on a set of indicators, but all of those indicators are medical indicators,” Bradley said, regarding the relationship between public health and medicine. “There’s a sweet spot where doctors could be happier because they actually get to do what they’re good at and what they want to do and what they’re trained to do without all of this other stuff.”


Social Entrepreneurship in Health


With the growth of the tech bubble, more and more institutions have devoted themselves to fostering a culture of innovation. Through large grants, hackathons and intense networking, schools like Yale have sought to empower student innovators. The Yale Entrepreneurial Institute (YEI), for example, was founded just seven years ago, though it did not attain truly substantial funding until this past year.

Professor Martin Klein wants to harness this enthusiasm for developing new ideas and direct it towards social impact in the healthcare sector. “Our focus isn’t any policy debate or insights into the ACA or where the healthcare system is moving. It’s very much targeted to help students come up with innovative solutions to current public health problems and challenges.”

“It’s already happening in other sectors,” he said. “We’re just taking some of the same ideas and applying them specifically to health.”

Klein’s idea, InnovateHealth Yale, goes far beyond the huge leaps codified in the ACA. His vision is truly at the frontier of the healthcare climate in the United States. According to Klein, this effort to explicitly incorporate  undergraduates into the health space is unprecedented. It is also extremely aggressive.

In the past year, InnovateHealth Yale has placed itself solidly within the Yale entrepreneurial community, forming relationships with the YEI, School of Management, and CEID, among others. Klein and his colleagues also just launched the Thorne Prize for Social Innovation in Health, which offers $25,000 to the best student venture in the field. Next Spring, they will offer a course in health innovation through a partnership with the Mayo Clinic Center for Innovation.

Klein’s program may be particularly noteworthy because it does not seek to produce change from inside the current healthcare system. Unlike Cha, Krumholz and Bradley — who are all working within a governmental or academic framework — Klein is not tied to restrictive structures. Rather, his methods can be broken down to a single sentence: “Take a really smart group of students, provide them support and encouragement, and see where they go.”

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