Meet the Expert: Guido Cataife

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Guido Cataife oversees about 20 projects within AIR’s health division, focusing on health care payment and delivery models. He directed the large-scale evaluation of the Medicare Appeals Demonstration and the operations subcontract for Kidney Care Choices, an alternative payment model, both for the Centers for Medicare & Medicaid Services.  

POSITION: Vice President, Health Evaluation, Methods and Analytics 

EXPERTISE: Alternative payment models, quantitative methods, health economics 

YEARS OF EXPERIENCE: 14
 

Q: What piqued your interest in a career in health economics?  

Guido: I’ve always been fascinated by the dichotomy of the U.S. and its health care system. It’s among the richest, most developed countries in the world, and yet its health care system has notorious problems: fragmentation, uncoordinated care, insufficient access, and vast inequities. U.S. maternal mortality rates are double or more those of other high-income countries, particularly for minorities and especially black women. And there’s a very basic problem of affordability for many. I wanted to better understand why this rich, developed country has these deficiencies that deeply affect our quality of life. 
 

Q: How do payment models affect the efficiency and equity of patient health outcomes? 

Guido: Payment models are all about incentives, and how they could be changed. In the U.S., many health care providers, including physicians, are paid for each service that they provide. This volume-based system leaves very little incentive for providers to contain health care costs, or even offer much preventive care, because those services are less financially rewarding. Of course, most providers have very strong ethics and the best intentions for their patients. Nevertheless, the system’s design means providers prioritize efficiency and being more reactive.  

One goal of alternative payment models is to give providers financial incentives to prevent or delay the progression of diseases. When a disease is prevented, or kept in more early manageable stages, Medicare saves money, and patients are better off. In some alternative payment models, Medicare shares those savings with the providers, as an incentive to increase these preventive services.  

Another version of alternative payment models ties Medicare payments to providers with specific performance measures, or patient health outcomes. If physicians offer patients screenings, vaccinations, and other preventive services, that should improve outcomes, and physicians will receive financial rewards for those actions. 

Payment models can also help reduce systemic health inequities. Consider a patient who lives in a rural, isolated area, who does not receive adequate ongoing care for a chronic condition. Most likely, they will eventually end up in the emergency department for what should be a controllable condition. The emergency department setting is extremely expensive, and the patient has experienced a critical health moment, likely resulting in worse health outcomes. Ideally, we would avoid all of that by facilitating timely care.  

Q: What role could new technologies and big data analytics play in payment models? 

Guido: Theoretically, big data or artificial intelligence (AI) could help us predict how health care costs would evolve, by showing us accurate counterfactuals. For example, when we implement a model, we don’t know what would have happened if we hadn’t—that’s a constant methodological problem that technology could help with. AI could also help providers identify gaps in the health care patients receive. Sometimes physicians have limited information and struggle to see the big picture. AI could find patterns—reminding physicians that patients with a given condition are more likely to develop related conditions as well, and suggesting further screenings.  

There are also many practical, seemingly small problems that it could help with: like reminding patients to take their medications, attend their appointments, or re-stating their physician’s instructions. Solving these seemingly small issues could make a major impact on actual health outcomes.  
 

Q: AIR is working with the Centers for Medicare & Medicaid Services (CMS) to improve care for individuals with chronic kidney disease. What makes these patients unique and well-suited to alternative payment models?

Guido: AIR has helped CMS improve care for individuals with chronic kidney disease (CKD) and end-stage-renal disease (ESRD) through various models, including the Comprehensive ESRD Care initiative, the Kidney Care Choices model, and the ESRD Treatment Choices model. One characteristic that makes these patients unique is that their condition exists on a continuum: it starts with CKD, which, when left untreated, ultimately progresses to ESRD. Once it’s reached that stage, it becomes extremely expensive for the health care system, and patients’ lives are upended. But if they’re diagnosed with chronic kidney disease early enough, the disease is much more easily contained and delayed, resulting in a much better quality of life and a reduced financial burden.

Another is that ESRD is extremely burdensome for patients, families, and the health care system. The most common treatment is maintenance dialysis, where patients usually visit a treatment facility three times a week. Of course, that’s very disruptive, creating transportation challenges, making it difficult to maintain a job, and so on. It’s also important to note that although dialysis is the most common treatment, it’s not the proven best treatment available. Patients who receive kidney transplants tend to live longer, have better health outcomes, and have reduced health care costs—though of course, there are obstacles to increasing the number of transplantations.  
 

Q: What major takeaways have you found from this work?  

Guido: Fighting CKD and ESRD requires a holistic approach. The original model CMS developed about 10 years ago focused on ESRD and the role played by dialysis facilities, which is important, but in retrospect we also know it is insufficient. We need to consider all stages of the disease. We should start with providing incentives for early screening and diagnosing, to keep the condition from rapidly progressing to its worst stages. We also need to work on maximizing the number of preventive transplants when possible. Then, of course, we also need to consider treatment options for ESRD when transplant is not an option, maybe due to insufficient number of kidney donors. That includes in-center dialysis, but also in-home dialysis, which is considered superior although not possible for everyone. It requires patients to undergo training and show that they can follow directions; their residence needs space for a dialysis machine and a clean area for the treatment; and so on. We need to be thinking about the condition from every stage and every angle. 
 

Q: What is the most common misconception around health care and payment models? 

Guido: There’s a tendency to underestimate the complexity of the problem. Even as researchers, we get very focused on the specific aspects we study, but we must always remember the big picture.  

For example, incentives can be very consequential in shaping our providers’ behaviors. But we still need to account for other issues, such as health care industry workforce shortages. If patients in rural areas—where shortages are most prevalent—can’t access care, then changing their providers’ incentives won’t be sufficient. And there are so many issues related to sedentary patient lifestyles, or even the relative prices of food—for example, the fact that processed food is more affordable than fresh produce. Of course, these are just a few examples of the many factors that influence patient outcomes. But when trying to reform the health care system, we have to consider how they play off each other. 
 

Q: Where can we find you on a typical Saturday?

Guido: I strive for a combination of physical and cultural activities. I live in Seattle, and I love hiking our many beautiful parks, lakes, and trails; my wife and I also canoe and paddleboard. I’m also an avid reader. And when a jazz or blues artist tours in Seattle, you can always find me at the show.   
 

Q: What book would you suggest everyone read?

Guido: I’m currently re-reading “Siddhartha” by Hermann Hesse, which I love. It’s a short, easy read—both entertaining and philosophical. It’s about a person who doesn’t know what he wants to be, and keeps exploring, in contrast to his best friend, who adopts a more passive approach to life. It raises questions about building our own path in life and finding our true selves.