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March 2018 (Volume 96)
Joshua M. Sharfstein
How do I love thee? Let me count the ways.
(Elizabeth Barrett Browning, Sonnet 43)
After all, you of all agencies would expect everything to be counted.
Ever since November 14, 2011, when you announced the availability of $1 billion in awards for innovation, you have helped tens of thousands of people in health care organizations think differently about their jobs.
These initial grants stirred excitement for health improvement in every corner of the country, from Alaska’s PeaceHealth Ketchikan Medical Center (“better health through coordinated care”) all the way to the University of Miami (“expanded activities for school health”). There have been more than 516 entities participating in programs, models, and grants with you, covering every state in the nation.
I love thee to the depth and breadth and height
Some people call this the triple aim; others, for some strange reason, the three-part aim. No matter. You are teaching the country a new goal: greater health at lower cost with an improved experience of care.
As a result, in many parts of the country, patients with heart failure need not return to the hospital, struggling to breathe, again and again.
With financial incentives in the right place, doctors and nurses can help these patients remain comfortably at home while eliminating the cost—and danger—of multiple hospital admissions.
My soul can reach, when feeling out of sight
For the ends of being and ideal grace.
You have lifted the “out of sight” into the national understanding of health care. Beyond heroic surgeries and emergency department visits, you have emphasized primary care, expanded access to mental health and addiction services, and encouraged the use of trusted community health workers to support people living with chronic illness.
You have acknowledged that health can be found in diet, physical activity, and behavior modification in patients with diabetes, through programs now reimbursable for the first time in Medicare.
You have embraced the truth that health requires access to safe shelter, nutritious food, and heat in winter, encouraging health care organizations to work with community partners, in Accountable Health Communities, to meet the basic needs of their patients. You have even made the groundbreaking decision to measure health at the community level, recognizing improvements in such outcomes as suicide and overdose across populations.
I love thee to the level of every day’s
Most quiet need, by sun and candle-light.
You have quietly pursued progress away from the storm of partisan politics. You have worked with states, red and blue; health systems, traditional and forward-leaning; and ideas, incremental and transformative.
You have supported a broad range of creative models, from medical homes in Utah to bundled payments in Arkansas to an all-payer accountable health organization in Vermont. In each case, you have let local leaders develop the political consensus needed to sustain reform. As a result, you have energized health departments, Medicaid programs, state houses, and governor’s offices across the country.
Incredibly, even as battles on insurance coverage raged in Congress, legislators of both parties came together in large majorities to support enhanced payment for physicians who participate in your models.
I love thee freely, as men strive for right.
I love thee purely, as they turn from praise.
Yes, indeed, some have “turned from praise.” These include pharmaceutical companies concerned about oncology models, as well as traditional orthopedic surgeons who objected to mandatory bundled payments for hip and joint replacement.
Alas, not every direction you have taken has been wildly popular. But you have engaged extensively with your critics, revised models in response to public comment, and sought input on new directions.
You’ve exemplified the point that the purpose of health policy is improved health at lower cost, not a standing ovation from “stakeholders.” At times, narrow interests have eclipsed the needs of patients and fiscal prudence. (It did not help that a traditional orthopedic surgeon became the secretary of the Department of Health and Human Services, however briefly.)
But by standing squarely with the evidence, you have created room for policymakers with courage and foresight to circle back to good ideas.
I love thee with the passion put to use
In my old griefs, and with my childhood’s faith.
I love thee with a love I seemed to lose
With my lost saints.
Where many caregivers have despaired about the mercenary nature of the health care system, you have reinvigorated a vision of health care for a higher purpose. You have allowed health care workers in hospitals, physician practices, long-term care facilities, community health centers, and home health agencies to dream up more effective and compassionate ways to provide care.
It is also true, however, that clinical transformation has yet to reach many on the front lines of medical practice. Caregivers remain burdened by documentation, hindered by time pressures, and frustrated with the electronic medical record.1
Your solution to these challenges has been to keep moving forward. There remains a great need to accelerate innovation, including change that comes right from those who know best what it means to provide high-quality, patient-centered care.
I love thee with the breath,
Smiles, tears, of all my life;
and, if God choose,
I shall but love thee better after death.
Your fate now rests with a new administration, one pledging to take you in a “new direction.”2 The goal is now to “empower patients” with “information to seek value and quality as they shop for services,” which sounds like a good idea, as well as “incentives to be cost-conscious,” which seems a bit Orwellian.
The administration has called for “a system that holds providers accountable for outcomes and allows them to innovate,” a vision well in keeping with your proud tradition. But it has also claimed that “patients can define value better than the federal government can,” which erroneously suggests that these paths are mutually exclusive.
Only time will tell whether you will still be able to challenge the health care system to become a better version of itself, still seek to realize the enormous potential in spreading good ideas quickly, and—most important of all—still measure success by improved health above all else.
You are a remarkable agency, staffed with devoted and creative public servants. This much is certainly true: When it is time to write the history of this era in health care in the United States, the story of the Innovation Center at the Centers for Medicare and Medicaid Services will merit a lot more than a sonnet.
Joshua M. Sharfstein is associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health. He served as secretary of the Maryland Department of Health and Mental Hygiene from 2011 to 2014, as principal deputy commissioner of the US Food and Drug Administration from 2009 to 2011, and as the commissioner of health in Baltimore, Maryland, from December 2005 to March 2009. From July 2001 to December 2005, Sharfstein served on the minority staff of the Committee on Government Reform of the US House of Representatives, working for Congressman Henry A. Waxman. He serves on the Board on Population Health and Public Health Practice of the Institute of Medicine and the editorial board of JAMA. He is a 1991 graduate of Harvard College, a 1996 graduate of Harvard Medical School, a 1999 graduate of the combined residency program in pediatrics at Boston Medical Center and Boston Children’s Hospital, and a 2001 graduate of the fellowship program in general pediatrics at the Boston University School of Medicine.
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