'No Debate,' Cleveland Clinic's Great. But How To Replicate?

by Dan Diamond, California Healthline Contributing Editor

TOPIC ALERT:

Despite better judgment -- or previous advice -- "Road to Reform" didn't take its own medicine and watched last week's presidential debate. And unsurprisingly, there was little new news for health wonks; President Obama and GOP challenger Mitt Romney disagreed on many policies both in and out of health care.

However, there was an unexpected moment: Both men found common ground on the Cleveland Clinic, agreeing that it's one of the nation's leading health systems -- even if they disputed how it got there. 

Meanwhile, the Clinic seized on the moment. The health system quickly launched a new microsite at http://www.clevelandclinic.org/nodebate, which offers videos of the candidates' debate comments. It also took out full-page ads in Sunday's New York Times and Monday's Wall Street Journal touting, "No debate. Both candidates agree" that the system is excellent.

That's certainly true; the Clinic has consistently been named to the top of the U.S. News & World Report hospital rankings and recognized for its low-cost, high-quality approach to care.

But there is debate over whether other systems can replicate the Clinic's model, and whether Obama's or Romney's reforms can help them get there.

Dueling Opinions

According to Obama, the Cleveland Clinic succeeds "because they do some smart things."

    They say, if a patient's coming in, let's get all the doctors together at once, do one test instead of having the patient run around with 10 tests. Let's make sure that we're providing preventive care so we're catching the onset of something like diabetes. Let's [pay] providers on the basis of performance as opposed to on the basis of how many procedures [they've] engaged in. Now, so what this board does is basically identifies best practices and says, let's use the purchasing power of Medicare and Medicaid to help to institutionalize all these good things that we do.

Under the Affordable Care Act, the president suggested that other hospitals could replicate the Clinic's success.

Romney concurred that the Clinic is one of the nation's top health care systems, saying that it does things "superbly well." However, Romney argued that the Clinic's achievements reflect private innovation, not government encouragement.

So who's right? In theory, both men are correct -- but they're arguing different points. Obama's Affordable Care Act incents providers to reproduce some of the hallmarks of the Clinic's model: more physician employment and a shift to multidisciplinary care.

But Romney's right that the Clinic's own history is one of independent physicians recognizing an opportunity to deliver better care, even at the expense of their own profits. And Obama's suggestion that the ACA's cost-cutting board, the Independent Payment Advisory Board, would somehow help other hospitals become Cleveland Clinics of their own is mistaken, Thomas Burton and Louise Radnofsky wrote on the Wall Street Journal's "Washington Wire." Specifically, IPAB may give providers incentives to more effectively practice medicine, but it is focused on controlling Medicare payments, not shaping how care is delivered.

(In fairness, Romney also "blurred" the board's role by suggesting that IPAB would mandate certain treatments, the Journal reports. It wouldn't.)

Clinic as Model

One reason that the Clinic came up during the debate is because the health system hasn't shied away from national attention. CEO Toby Cosgrove told a Senate committee hearing in June 2009 that the Clinic should be a model for health care reform, and since then he has given a slew of interviews touting its approach.

But that still leaves many providers with a nigh-unanswerable question: How do we become Cleveland Clinic -- or Mayo Clinic or Intermountain Health Care, for that matter?

After being founded in 1921, it took the Clinic more than two decades to find its footing, and that was during a much less competitive time for health care. Today, moving from a traditional health system to group practice model requires enormous behavioral shifts and a huge investment in physician employment. It's a tremendously risky move that hospitals have rarely tried.

Perhaps the most prominent attempt is the organization formerly known as Carilion Health System, which in 2006 announced plans to transition away from a traditional health system to a clinic-based model.

But as the Carilion Clinic, the organization has run into trouble; the area's independent doctors protested the shift, and the organization was forced to dip into assets to navigate the economic downturn.

Alternately, hospitals can adopt an approach that "Road to Reform" will term "if you can't be them, join them." A number of organizations have partnered with the Mayo Clinic in its new Care Network, and the Cleveland Clinic is also expanding its affiliation strategy. Both Mayo and the Cleveland Clinic say the model will help other providers make a necessary move to new payment reforms.

Cleveland Clinic Stays Above Fray

While Cleveland Clinic staffers were excited by Obama and Romney's praise, the organization's mention during the presidential debate was borderline ironic -- its leaders have tried to avoid being drawn into the political debate over health reform.

For more than three years, CEO Cosgrove has been careful in interviews to balance touting the positives of the Affordable Care Act, such as expanded health coverage, with accompanying cautions that the ACA will raise health costs and cut payments to providers.

And despite the Clinic's own self-anointed status as a care innovator and its own accountable care pilots, the organization opted not to apply for the government's Pioneer ACO program -- despite likely profits -- as Jenny Gold of Kaiser Health News reported.

As a result, the Clinic has remained officially neutral on the ACA, a careful and cautious position in a battleground state.

Which is why one choice on the system's "No debate" microsite is surprising. It may be telling, or it may be nothing -- but the Clinic's own edited video of the candidates doesn't end with Romney touting the health system as one of the nation's best. Instead, he continues for another sentence:

    But the right answer is not to have the federal government take over health care and start mandating to the providers across America, telling a patient and a doctor what kind of treatment they can have.

Here's what else is happening around the nation.

Administration Actions

  • CMS has awarded a $3.1 million contract to public relations firm Weber Shandwick to promote the federally run health insurance exchanges under the Affordable Care Act. The contract stipulates that Weber Shandwick will be responsible for raising awareness, educating U.S. residents and conducting outreach efforts. The contract runs through April 2013 -- months before the federal exchanges will be operational -- with an option for an additional year (Baker, "Healthwatch," The Hill, 10/4).

Challenges to Reform

  • Last week, the U.S. Supreme Court signaled that it is considering a request by Liberty University to hear a lawsuit challenging the ACA's individual mandate (Baker, "Healthwatch," The Hill, 10/1). Liberty asked the Supreme Court to invalidate an appellate court's ruling in the case and argued that the high court wrongly dismissed the case based on its June ACA ruling (Haberkorn/Cheney, Politico, 10/1). The high court has asked the Department of Justice to respond within 30 days to the request, which could indicate that some justices are interested in hearing the case (Cheney, Politico, 10/1).

In the States

  • A large portion of New Mexico's costs to expand Medicaid under the ACA would be offset by additional tax revenues generated from increased spending on medical services, according to a new legislative report (Massey, AP/CBS News, 9/28).
  • A number of counties in Texas are backing away from statements they made over the summer that they were considering going forward with a Medicaid expansion under the ACA at the local level, despite Gov. Rick Perry (R) opting out of the expansion on the state level (Smith, Politico, 10/3).
  • During a debate on Thursday, Utah Gov. Gary Herbert (R) and Peter Cooke, his Democratic gubernatorial challenger, briefed voters on their positions on the ACA's Medicaid expansion, which Herbert argued would be unsustainable for the state and Cooke described as a "smart business decision" (Gehrke/Stewart, Salt Lake Tribune, 10/5).

Rolling Out Reform

  • Roughly two dozen states missed HHS' soft deadline on Oct. 1 to submit their essential health benefit benchmark plans, according to data from Avalere Health. About half of the states that missed the deadline are led by Republicans and at least five have a Democratic governor. Nearly all the states that missed the deadline cited a lack of formal federal guidance as reason for the delay (Millman, Politico, 10/4).

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