« October 2016 Issue

A Longtime Innovator and Collaborator Takes on a New Role: A Chat with Bob Master

In March of this year, Bob Master, MD, the founder and former president and chief executive officer of the Commonwealth Care Alliance, joined the Center for Consumer Engagement in Health Innovation as a Senior Fellow. In this role, Bob serves as a strategic advisor and thought leader to the Center, focused on the goal of improving care for vulnerable populations.

Bob has had a long affiliation with Community Catalyst where, as a Soros/Open Society Institute Fellow, he incubated the plan for the Commonwealth Care Alliance (CCA), a Boston-based non-profit health plan and delivery system focused on providing patient‐centered, team-oriented care to vulnerable populations. Beyond the conceptualization stage, CCA began its operations in 2003 out of rental space within Community Catalyst’s offices, building upon the organization’s infrastructure and knowledge base, and Community Catalyst Executive Director Rob Restuccia served as the first President of CCA’s Board. Community Catalyst used its broad reach to share and promote the best practices operationalized by CCA. The Commonwealth Care Alliance is now a nationally recognized model for providing high-quality, low-cost care to dually eligible individuals who receive health coverage through both Medicare and Medicaid. 

Bob is a practicing physician at Boston Medical Center and is an Associate Professor of Public Health at Boston University’s School of Public Health, where he previously served as Chair of the Health Services Department.

When did you first begin to focus your own work on caring for those in vulnerable and underserved communities?

The first model really goes back to the 1970s. Working with a number of pioneering colleagues, we created a non-profit clinical practice – The Urban Medical Group – in one of Boston’s inner city neighborhoods. Our mission was to develop more effective approaches to populations and individuals with complex medical and social needs. These folks just weren’t being adequately served in the existing fee-for-service payment system and fragmented delivery system. That’s where we incubated the first generation of the team model of care, aided by a grant from the National Science Foundation that funded a demonstration and evaluation of the model for inner city nursing home patients. These patients were not getting any care in their facilities, and were instead relying on big academic medical centers for their care. Also, with support from the Robert Wood Johnson Foundation, we developed team models of care for homebound frail elders.

Did this represent a first-in-the-nation demonstration of this type of care model?  

The nursing home team model was first-in-the-nation, as was a care model we developed for people with involved physical and developmental disabilities. Also unique at that time was our collaboration with the emerging disability advocacy community, such as our friends at the Boston Center for Independent Living. Learning from and collaborating with members of this pioneering community has always been a key strategy in the design and continued evolution of the team care model.

What were the goals being pursued, in addition to providing better care to people, in the innovative efforts of this period?

In the 1970s and 1980s, it really was about testing the efficacy of these new models of care in the context of the existing reimbursement system – fee-for-service Medicare and Medicaid.  Most of our patients were beneficiaries of these programs, and the question was: Could this be a more effective approach to care, empowerment, independence and autonomy and also reduce the cost to the public payers? Those were the first questions, since the major drivers of cost were the missed opportunities to prevent avoidable hospitalizations.

A second stage began in the 1990s when it became clear it was really very difficult to implement – in today’s language – person-centered care and continuity of care in a fee-for-service environment. So in the 90s, we began the first experimentation with interdisciplinary team models in a risk-adjusted capitated payment context. It was an experimental effort within the Massachusetts Medicaid program.

In what ways did the incubation and launch of the Commonwealth Care Alliance build upon this work?

We found our efforts beginning to show real promise that this approach to primary care – particularly  in a prepaid financing context, as opposed to the fee-for-service context – was effective in achieving these goals, but achieving them at a small scale. The question was: Could this work at a larger scale? Commonwealth Care Alliance (CCA) was the next iteration and focused on showing that it could, just as Medicare and Medicaid were piloting the first dual eligible demonstrations beginning around 2002 and 2003. Incubated at Community Catalyst, CCA was incorporated as a non-profit in 2003.

What were the distinguishing features that went into developing the CCA model?

Many features of the care model redesign revolved around the allocation of resources, particularly Long-Term Services and Supports. If I had to say what the “secret sauce” was – it was listening to and respecting what the people had to say who were most impacted – given their life circumstances or clinical circumstances – about what works and what doesn’t work for them. Having those constituencies involved in the design, nurturing and evolution of these care systems: that was a cornerstone of all of this work and of CCA’s creation. Being at Community Catalyst during CCA’s incubation was incredibly beneficial, as staff were very involved in helping figure out diverse avenues for meaningful partnership engagement with consumers.

At this moment in time, considering the many provisions within the ACA focused on moving toward innovation and value and improvements in quality of care, what do you see as opportunities to build on past successes?

I think there is a substantial opportunity and synergy with all the prior work I’ve described. And that is that all these redesigned elements, large and small, were shaped in a very intense partnership with the various advocacy and consumer communities. It’s been gratifying to see how the arc of our work here in Massachusetts has impacted national policy and, clearly, the efforts to replicate this in many other states. Community Catalyst, with its partner relationships in over 40 states, is in a position that allows it a great opportunity to inform consumer advocacy in areas of policy, procurement and clinical programs.

What do you see as the Center’s role in seizing upon these new opportunities, and your role within the Center?

The ACA has opened new windows of innovation at the federal level. Delivery reform is front and center. You have new attention being paid to social determinants of health, to which the existing system of care has had few answers. These are the areas of opportunity.  As the driving force within Community Catalyst for articulating the goals of care system redesign, the opportunity to scale up upon the fundamental cornerstones of our past work, to inform the appropriate policy oversight and the redesign of clinical care systems – those are the goals, and the Center seeks to make the full circle from our earliest efforts.

In all our efforts across the spectrum of health system transformation, the power of the provider-consumer collaboration will be a touchstone. I am so excited to be able to apply my years of on-the-ground experience to helping inform the Center’s advocacy efforts, aimed at building new systems of care for vulnerable populations, and to teaching providers and plans how to implement these new models in person-centered ways.

Bruce Gore, Communications Coordinator