Pilots, Demonstrations & Innovation in the PPACA Healthcare Reform Legislation

Here’s a bit of trivia that will make you the hit of the next cocktail party you attend.  How many times are the words “demonstration” and “pilot” mentioned in the newly passed Federal healthcare reform legislation — the Patient Protection and Affordable Care Act (PPACA)?

Answer:

• “demonstration” — 312 mentions
• “pilot” — 80 mentions

This weekend I’ve been trying to wrap my head around the question “Just what are these demos and pilots in the PPACA all about?” I have been boggled by the sheer number and complexity, and thought I’d share some findings from my first dive.

Why are These Pilots and Demonstrations Important?

One of the most frequently voiced criticisms of the PPACA is that it doesn’t do enough about controlling costs through delivery system reform. I’d agree that this is the biggest flaw in the legislation.

That said, the pilots, demonstrations, and the creation of the Center for Medicare and Medicaid Innovation (CMI) are the best efforts in the PPACA to control future costs.  Whether they will work deserves further scrutiny, but today I’d just like to list and briefly describe these initiatives.

Keep in mind the distinctions between pilot and demonstration projects. In short, the Secretary of Health and Human Services (HHS) will have the authority to expand pilot programs and put them into practice without requiring Congressional approval.

What are the Pilots and Demonstrations in the PPACA?

I count at least 5 pilot projects and 30 demos in the PPACA legislation.

Here are some of the pilots and demos that I believe will be of most interest to e-CareManagement readers. (A full listing of pilots & demos is shown at the bottom of the post).

Pilots

Sec. 3023. National pilot program on payment bundling
Sec. 4202. Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries
Sec. 4206. Demonstration project concerning individualized wellness plan
Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers

Demos

Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization
Sec. 2705. Medicaid global payment system demonstration project
Sec. 2706. Pediatric Accountable Care Organization demonstration project
Sec. 3024. Independence at home demonstration program
Sec. 3027. Extension of gainsharing demonstration
Sec. 2601. 5-year period for demonstration projects. (for dual eligible beneficiaries)
Sec. 3140. Medicare hospice concurrent care demonstration program.
Sec. 3510. Patient navigator program.
Sec. 4206. Demonstration project concerning individualized wellness plan.

What’s The Center for Medicare and Medicaid Innovation (CMI)

Section 3021 of the enabling legislation also establishes the Center for Medicare and Medicaid Innovation within CMS. According to the Democratic Policy Committee,

The purpose of the Center will be to research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care provided to patients in each program. Dedicated funding is provided to allow for testing of models that require benefits not currently covered by Medicare. Successful models can be expanded nationally. [Thus appear better to fit the definition of “pilots”]

18 different models are listed for possible testing:

(i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need individuals
(ii) Contracting directly with groups of providers of services and suppliers
(iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care of  individuals with multiple chronic conditions
(iv) Promote care coordination between providers of services and suppliers that transition health care providers away from fee-for-service based reimbursement and toward salary-based payment.
(v) Supporting care coordination for chronically ill  individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology.
(vi) Varying payment to physicians who order advanced diagnostic imaging services
(vii) Utilizing medication therapy management services
(viii) Establishing community-based health teams to support small-practice medical homes
(ix) Assisting individuals in making informed health care choices by paying providers of services and suppliers for using patient decision-support tools
(x) Allowing States to test and evaluate fully integrating care for dual eligible individuals
(xi) Allowing States to test and evaluate systems of all-payer payment reform
(xii) Aligning nationally recognized, evidence based guidelines of cancer care with payment incentives
(xiii) Improving post-acute care through continuing care hospitals that offer inpatient rehabilitation, long-term care hospitals, and home health or skilled nursing care during an inpatient stay and the 30 days immediately following discharge
(xiv) Funding home health providers who offer chronic care management services to individuals
(xv) a collaborative of high-quality, low-cost health care institutions that is responsible for– best practices and proven care methods
(xvi) Facilitate inpatient care through the use of electronic monitoring by specialists based at integrated health systems
(xvii) Promoting efficiencies and access to outpatient services through models that do not require a physician or other health professional to refer the service
(xviii) Establishing comprehensive payments to Healthcare Innovation Zones, consisting of groups of providers

For more information about the Medicare CMI, see Medicare’s Opportunity to Encourage Innovation in Health Care Delivery, New England Journal of Medicine; March 3, 2010

Again, this blog post is simply intended to share findings about the sheer number and complexity of pilots and demos in the PPACA. I’ll be writing a lot more in future posts about specific projects and innovation  opportunities in Medicare.

APPENDIX — A Listing of Pilot & Demonstration Projects in the PPACA (abstracted from Senate Democratic Policy Committee, The Patient Protection and Affordable Care Act as Passed, Section by Section Analysis, March 2010)

Pilots

Sec. 3023. National pilot program on payment bundling
Sec. 3504. Design and implementation of regionalized systems for emergency care
Sec. 4202. Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries
Sec. 4206. Demonstration project concerning individualized wellness plan
Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers

Demonstrations

Sec. 2705. Prohibiting discrimination against individual participants and beneficiaries based on health status
Sec. 2403. Money Follows the Person Rebalancing Demonstration
Sec. 2601. 5-year period for demonstration projects. (for dual eligible beneficiaries)
Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization
Sec. 2705. Medicaid global payment system demonstration project
Sec. 2706. Pediatric Accountable Care Organization demonstration project
Sec. 2707. Medicaid emergency psychiatric demonstration project
Sec. 3024. Independence at home demonstration program
Sec. 3027. Extension of gainsharing demonstration
Sec. 3113. Treatment of certain complex diagnostic laboratory tests
Sec. 3123. Extension of the Rural Community Hospital Demonstration Program
Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties
Sec. 3131. Payment adjustments for home health care
Sec. 3140. Medicare hospice concurrent care demonstration program
Sec. 3208. Making senior housing facility demonstration permanent
Sec. 3508. Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals
Sec. 3510. Patient navigator program
Sec. 4102. Oral healthcare prevention activities
Sec. 4204. Immunizations
Sec. 4206. Demonstration project concerning individualized wellness plan
Sec. 4306. Funding for childhood obesity demonstration project
Sec. 5304. Alternative dental health care provider demonstration project
Sec. 5317. Demonstration grants for family nurse practitioner training programs
Sec. 5507. Demonstration project to address health professions workforce needs; extension of family-to-family health information centers
Sec. 5509. Graduate nurse education demonstration program
Sec. 6112. National independent monitor demonstration project
Sec. 6114. National demonstration projects on culture change and use of information technology in nursing homes
Sec. 6801. Sense of the Senate regarding medical malpractice
Sec. 10504. Demonstration project to provide access to affordable care
Sec. 10607. State demonstration programs to evaluate alternatives to current medical tort litigation