“Race to the Top” for Health Care: Will Don Berwick be our Arne Duncan?

Mike Magee MD

In July, 2009, as the battle remained fully engaged on a legislative fix for health care reform, a very different approach to educational reform was announced in Washington. The United States Department of Education released the draft priorities, requirements, definitions and selection criteria for the $4.35 billion “Race to the Top” grant program (RTT) of the American Recovery and Reinvestment Act of 2009 (ARRA). The program was ambitious, demanding and decentralized. (1)

Secretary of Education Arne Duncan, a consensus candidate from inside the Educational Sector, framed the effort as Education’s “moon shot.” “It is a once-in-a-lifetime opportunity, and this Department will not pass that up,“ he said. (2)

President Obama stood side-by side with Secretary Duncan at the launch. That day the President explained that education was one of the four critical pillars for economic success. The others? Energy reform, financial reform, and last but not least health reform. Focusing on education that day he said, “Even if we do all of those things (energy, financial, health), America will not succeed in the 21st century unless we do a far better job of educating our sons and daughters,” said the President. “In an economy where knowledge is the most valuable commodity, the best jobs will go to the best educated whether they are in the United States or India or China.” (2) It was clear that President Obama was squarely behind the RTT initiative.

One year later, it’s interesting to reflect on the two very different approaches taken to radically transform education on the one hand, through a decentralized and competitive approach driven by the Executive Branch of Government, versus a more centralized and moderate reform agenda for health driven by the Legislative Branch of Government.(3) It is unclear how fast and how far Health Reform will go since we are clearly at the front end of that process. But less then a year since Arne Duncan’s effort was announced, most experts are expressing surprise at it’s massive and transformative impact. (4,5)

I’ll describe that effort more in a moment. But before I do, let’s look at comparisons of the Education and Health Sectors. In both cases, it has been widely accepted that there is pervasive sector failure on multiple levels and that the status quo is no longer an acceptable fall back position. In both cases, that status quo has remained the protectorates of power silos such as the teachers’ and principals’ unions on the one hand and the health insurance, organized medicine, hospital, pharmaceutical and device industries on the other. In both cases, budgets and financial obligations are breaking the backs of local, state and federal governments. In both cases there are high levels of variability in outcomes, with minorities fairing worse then the general population. In both cases modern information infrastructure, with universal compatibility and consistent longitudinal data capture with analysis is dramatically deficient. As a result, the capacity to measure outcomes reliably, and tie human resource performance to outcomes of pupils or patients is highly deficient. In both cases, strategic use of technology to leverage connectivity, complexity and consumerism and deliver services with greater efficiency and effectiveness has remained highly underdeveloped. In both cases money is tied to brick and mortar (the hospital, the medical office, the schoolhouse) and does not reliably follow the pupil or the patient.

Now let’s look a little closer at the criteria for selection of states in “Race To The Top” (RTT). 40 states and DC submitted grant applications in Phase I of the competition. As you read the expert summary below (6) , consider how a mirror process might advance health transformation were we to have a “Race to the Health Top” (RTHT). To assist you, I’ve added parallel health terms in parentheses.

The experts say (6) :

“There are four core RTT (RTHT) priorities. The first “absolute” priority, or one that must be met, requires a comprehensive approach to the four reform areas in the Recovery Act. The four connected reform areas are: teacher (health professional and health team) effectiveness, higher standards and rigorous assessments, effective school turnaround (universal coverage and multi-generational continuity of care for all), better use of data. The first priority also requires a description of how the state intends to use the RTT (RTHT) funds to implement policies and practices in these four areas that are designed to increase student achievement (health and full human potential), reduce the achievement gap (health disparities) across student (patient) subgroups, and increase rates in which students (health consumers) graduate from high school prepared for college and careers (maintain healthy behaviors, practice prevention, reinforce family and social bonds, and demonstrate high productivity in the home and work place).

“Priorities two through four are invitational priorities, or priorities that, if met, will enhance the state’s application. Priority two is an emphasis on science, technology engineering and mathematics (science and technology to improve efficiency and effectiveness of health care delivery, maintenance and prevention). Priority three solicits P-16 education system coordination(health delivery coordination) that attempts to make early childhood through higher education a seamless experience for students (longitudinally tracks personalized and prospective health planning and delivery from conception to end of life care). Priority four solicits applications that extend current statewide longitudinal data systems to integrate data from special education, early childhood, human resources, finance, and other relevant areas related to education and social policy (from hospitals, health professionals, health insurers, pharmacies, pharmaceutical and device manufactures, scientific researchers, health consumer and health technology manufacturers, and health consumers themselves).

“There are two critical eligibility requirements that will certainly receive many comments. The first is that states must have no legal, statutory, or regulatory barriers to linking data about student achievement or growth to teachers for the purpose of teacher and principal evaluation (about patient outcomes to health professionals and health care teams for the purpose of performance evaluation). Any change to such a barrier promises to be contentious. The second is that the state’s application for funding under phase 1 and phase 2 of the State Fiscal Stabilization Fund must be approved by ED(HHS?) at the time the award would be made to the states under RTT (RTHT).

“There are eight application requirements that must be met when submitting applications. Although all are notable, there are two that stand out. According to the third requirement, the state must demonstrate statewide support from stakeholders (health care stakeholders). Given the focus on teacher (health team) effectiveness, human capital, and school turnaround (turnaround of failing health delivery systems) this will likely be easier said than done.

“Requirement number eight demands the state to provide, for each plan criterion, a detailed plan that includes the activities to be undertaken, the party responsible for implementing the activities, the resources the state will use to support the activities, and the state’s annual targets for the performance measures aligned to the criterion. The amount of work embedded in this requirement is considerable and demonstrates just how organized ED (HHS?) expects these applications to be. Project management and oversight cannot be understated.

“After making it through the grant’s four priorities, two key eligibility requirements, and eight application requirements, the states finally arrive at the selection criteria. There are 22 selection criteria that states may address when submitting their applications. The race truly begins here. For each identified reform, ED (HHS?) plans to use two types of selection criteria: “baseline criteria” and “plan criteria.” The “baseline criteria” rewards states for having created conditions for reform, and the “plan criteria” provide incentives for states to implement innovative reform strategies that integrate across the reform areas.

“Of the proposed selection criteria a few stand out.

“First, ED (HHS?) endorses national standards by requiring applicants to have joined a consortium of states to jointly develop and adopt by June 2010 a set of internationally bench-marked K-12 standards (health outcome standards) that build toward college and career readiness by the time of high school graduation (well established health knowledge and behaviors by age 18).

“Second, ED (HHS?) requires the development of longitudinal data and the use of that data across all education sector levels (health delivery, health prevention and health maintenance levels). From the state policy level to the teacher’s weekly lesson planning (health policy to health planning and delivery) data-driven-decision-making is critical.

“Third, the question will no longer be if states differentiate teacher and principal effectiveness based on student performance (health team effectiveness based on health consumer performance), but how they will do so and how that will effect the hiring and firing of teachers and principals (job descriptions, evaluations and hiring and firing of health team members). The RTT (RTHT) peer reviewers will also consider the extent to which the state has a high quality plan that includes ambitious but achievable annual targets to increase the number and percent of teachers and principals (health professionals and health teams) in high-need schools (high need health disparity regions) who are effective.

“Finally, a charter school law (breakthrough home-centered health law) will be required, and that law must not prohibit or effectively inhibit increasing the number of charter schools (home-centered health delivery systems) in the state or otherwise restrict student enrollment (patient enrollment) in charter schools (home-centered health delivery model sites).

“Participation in this grant will require that states provide annual reports describing their progress versus plans and how they have adhered to an annual fund drive-down schedule that is tied to those goals, time lines, budget and annual targets. Applicants that are selected will likely be required to enter into a written performance or cooperative agreement with ED (HHS?), and if the state is not fulfilling its commitments, it may be put in high-risk status, be placed on a reimbursement payment system, or have its funds withheld.” (6)

Now with such a demanding process, you’d expect that Educational Reform today would be far behind Health Reform. Yet just the opposite is true.(7) In fact, the competition has been vigorous, and in Phase I, only two states (Delaware and Tennessee) made the grade out of 40 submissions. This week, 19 additional states were identified as finalists for Phase II, with 10 to 15 predicted to eventually receive funding. So nearly half of the original applicants have already been rejected. For those who have prevailed, what changes were required? First, all stakeholders (including teachers unions) were required to sign Memorandums of Understanding (MOU’s) agreeing to abide by reform principles. Second, states unwilling to dismantle laws that prevented the use of student performance measures in teacher evaluation or unwilling to define new models to deal with over protection of teacher tenure at any cost (high priority legislative goals of some teachers unions) were openly rejected in Phase I. (8)

Rejection in Phase I, occurring during a strong economic downturn, with high unemployment and huge state budget deficits where educational budget obligations were a major offender, have created a legislative environment that has shifted 180 degrees in a matter of months. Combine this with the entry of three groups of educational professionals with non-traditional backgrounds who are deeply committed to parallel reform of the educational sector and you begin to understand the power of this transformational movement. The first are entrepreneurial charter school operators. The second are educational public advocacy groups focused on the achievement gap between whites and minority students who aggressively share real time performance data on each and every school in their catch basin online with parents seeking the best choice and the best chance for their children. The third group are professional government relations personnel attracted to the education space by “Race To The Top”, and the required enabling legislation that would allow states to win a grant and insure that money follows the pupil whether traditional public or charter schools. (4,5,8,9)

Could RTHT work? Not if it is designed like the HIT grant process which lacks true transformative criteria and channels money through existing brick and mortar driven health power silos. The 975 million is tactical and aimed at converting paper records to electronic medical records. Where RTT sees information technologies as a transformative tool, the HIT process is under visioned and not anchored by a new health delivery system vision where health is about full human potential and record systems are no longer passive repositories for yesterday’s data, but rather organizing platforms to allow customized and personalized strategic health planning 120 years forward. (10)

That aside, what if there were an RTHT, as powerful in design and execution as the RTT, could it work? Maybe. Some would argue the health care segmentation and disintegration is far more severe in the Health Sector then in Education. To that I would respond that, while it may be true, understand that all that segmentation and disintegration has been deliberate and purposefully supported by each and every health silo in power today. The bullying behavior has been intentional, deliberate, and well funded. Faced with a competitive opportunity to truely race to the health top, I expect these entities would rapidly fall in line, as has been the case in Education. As for a vision as powerful as RTT, I believe we pretty much know where we need to go and could concisely define it in great detail now. (11) So why do I say “maybe”?

The simple answer is, “We have no Arne Duncan.” To manage a process like RTHT, you need a premier leader, from the inside of the sector, known and respected by all parties, politically skilled, who not only possesses a powerful transformative vision but has the energy and passion to accomplish its realization. Could that be Don Berwick? (12) Maybe. But one thing is for sure, absent our own Arne Duncan and a distributive process like RTT, plan on education and energy and financial sectors reaching for the future while we remain mired in the past. Absent our own “Arne Duncan”, there is no RTHT. And absent an RTHT there is no “moon shot” for health care.

For Health Commentary, I’m Mike Magee

References:

1. ED.gov. 40 states, DC submit applications for Phase 1, “Race to the Top”.http://www2.ed.gov/news/pressreleases/2010/01/01192010.html

2. ED.gov.http://www.ed.gov/blog/2010/01/race-to-the-top-41-applications-submitted-for-phase-1/

3. AAFP. “Congress passes comprehensive Health Reform Bill”.http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20100321reformpasses.html

4. ConnCAN. Lawmakers act quickly with Phase I of “Race to the Top”.http://www.conncan.org/media/lawmakers-act-quickly-first-step-towards-race-top-success

5. Race Smarter: Rhode Island. Why it lost and what it can do to win.http://www.dfer.org/Rhode%20Island%20Race%20Smarter%20Brief.pdf

6.Deschryver, D. Analsis: Race to the Top guidelines ambitious, demanding. July 30, 2009.http://www.thompson.com/public/newsbrief.jsp?cat=EDUCATION&id=2279

7. NCTQ. A Race to the Top Scorecard.http://www.nctq.org/p/publications/docs/nctq_race_to_top_scorecard.pdf

8. Klein E. “Race to the Top actually forcing states to run. Washington Post. March 30, 2010.http://voices.washingtonpost.com/ezra-klein/2010/03/race_to_the_top_actually_forci.html

9. Marshall W. “Get ready for school turnaround”. Progressive Fix. May 24, 2010.http://www.progressivefix.com/tag/race-to-the-top

10. Summary HHS HIT Grant Program.http://www.aamc.org/members/gir/hit/grants.pdf

11. Magee M. Powering Healthcare Visions: Taking Advantage of Complexity, Connectivity, and Consumerism. Intel Technology Journal. Volume 13, Issue 3. December, 2009. http://www.intel.com/technology/itj/2009/v13i3/index.htm

12 Pear R. Obama chooses health policy scholar to head Medicare. NYT. http://www.nytimes.com/2010/03/28/health/policy/28health.html