After spending four years at Highmark Inc., Michael Madden has returned to Gateway Health Plan as its new chief medical officer, with a bright office overlooking the Golden Triangle.

The Pittsburgh-based Medicaid managed care organization has about 300,000 customers, and as the CMO, Dr. Madden is now responsible for overseeing Gateway's quality measurement and pay-for-performance programs.

Dr. Madden earned his medical degree from Georgetown University School of Medicine and received his medical management certification at Carnegie Mellon University.

He sat with the Post-Gazette for an interview recently, discussing his new job, health care reform, and increased enrollment in Medicaid programs, due to the balky economy.

Q: What are Gateway's biggest challenges right now?

A: With the difficulties in the state budget, we have to figure out ways to provide incredibly high-quality care that's also very cost-effective and stay focused on the needs of a really complex membership. ... The combination of [our Medicaid customers and our Medicare special-needs plan clients] puts a very heavy disease burden .... Our special-needs plan is more than 50 percent folks who have disabilities. It's not just elderly .... They have complex needs, both medical and social.

Q: How do the state budget negotiations affect your spending?

A: For the last three or four years, the state budget has only allowed us a 2 or 3 percent increase in medical cost trends, relative to commercial medical cost trends being 6, 8, 10 percent. And it wasn't like we were getting too much money before that. It's an amazing thing that we've been able to manage to that budget so far.

Q: At Highmark, you focused programs on pay-for-performance and improving ambulatory care. Talk about your time there.

A: The thing I'm happiest about [is] that I think we started to change the culture of ambulatory practice with one of the measures that was part of our pay-for-performance program, which we called the best-practice component. [We] actually, for the first time, got practices to do their own measurable quality improvement projects ... same kinds of things most other industries have been doing for a long time, but really is not existent within ambulatory care.

Q: Why have physicians and health systems been slower to adopt best-practice methods and quality-control research? Are doctors afraid of practicing "cookbook" medicine?

A: It was never part of the culture of medicine to measure their quality and intervene and re-measure it -- amazingly. ... Not that they didn't try to do things new or in a different or better way, but that there was never a focus on measuring whether that made a difference. ... I think part of it is a perception that care should be individualized for every patient.

And there are some aspects of care that should.

But there's also a lot of aspects of care that should be standardized, for all patients -- immunizations, being sure that certain screening tests are done. ... Also, the culture of medicine has been that quality was assumed if you studied hard and went to a good residency and worked hard. [We] focused on how much knowledge was crammed into the doctor's head.

Q: Why are best practices and best treatments so difficult to settle on?

A: We're fortunate to have in a number of diseases lots of choices now -- various drugs you might use to treat high blood pressure or diabetes ... unfortunately, historically, nowhere near enough research has been done to prove [which drug is better].

Most research has been funded by somebody who had a device to fix something or a drug to fix something. All the FDA cared about was, "Does that work?" Not, "Does that work better than the other choice?" Fortunately, with the stimulus money, there are now significant funds to fund that kind of research. ... but they also mandated that it doesn't include cost-effectiveness. It only [studies] relative clinical effectiveness.

Q: Why should you be studying both?

A: Proving that a particular therapy -- maybe it's a hip replacement -- has a good outcome is great. But wouldn't it be great if we could find that physical therapy got to almost as good an outcome, for a tenth of the cost?

Q: You get a budget each year from the state and you work within it. What lessons can you offer to insurers, physicians and hospital systems that worry about the federal government installing cost and payment restraints as part of the health care reform package?

A: Working within a budget forces you to be more creative, in looking at different solutions other than, "We have to charge more, or get more money." ... What I think it's forced us to do is look at patients more holistically than a lot of commercial insurance plans may.

Q: "Rationing" is a bit of a dirty word these days.

A: I think that there's a lot that can be done if we [realize] that more isn't necessarily better, and allow people to follow out what's the best or better way to take care of thinks, and then put programs in place that encourage, maybe even force, people to move down those paths. ...

Some people might call that "rationing." I would call that "rational" care.

Q: What's the worst thing that could come out of the health reform debate?

A: Probably not acting would be the thing that really scares me the most. We need to do something.

We need to reinvent the payment structures. We've got to figure out strategies to support primary care in ways that we haven't before. It's been proven time and again to be the most cost-effective care [relative to emergency room visits or trips to specialists], yet it's our lowest-reimbursed care.

Q: It's easy to blame health insurers and providers for ever increasing costs. But to what degree are we as patients and receivers of care to blame, especially on diet and obesity issues?

A: It certainly starts with the schools ... trying to have every kid participate in an after-school activity type of program ... educating parents of the concept of two hours a day, maximum, of any kind of screen time -- TV, computer, video game -- is the most a child should ever have growing up, summers and winters. ... It's a societal issue -- city planners, policy-makers, all need to recognize a role, to deal with the obesity problem.

[But] ultimately, it is trying to get every single person to recognize that our lifestyle causes obesity, because of it being sedentary and fast-paced and automobile-focused.

Q: What about all the TV advertising done by pharmaceutical companies? Do you think the pervasiveness of the ads might lead some of us to believe that, no matter how badly we treat our bodies, there's a pill to fix it?

A: My own personal opinion is that direct-to-consumer advertising hasn't helped us.

There are a couple of situations where it's maybe created better awareness of a condition -- erectile dysfunction is an obvious example -- and allowed people to talk about subjects that may have been taboo before. [But] I don't know that you can really do a great job of educating in 30 or 60 seconds.