Monday, March 8, 2010

Testing Pilots, Demonstrations, Models of Care in Health Care Reform: Say What About the Proposed Center for Medicare and Medicaid Innovation (CMI)?

The Disease Management Care Blog still believes the terms "Medicare" and "innovation" are oxymoronic, despite Rob Mechanic and Stuart Altman's New England Journal of Medicine article on the potential for a new era of enlightened government health care. In a well-written if rather fawning Perspective piece, they argue that an efficient, responsive and nimble CMS is only ten billion dollars away, assuming, of course, that health reform passes.

How so? They point out that pending legislation will establish a Center for Medicare and Medicaid Innovation (CMI). Its purpose will be to test health care delivery models that reduce cost while maintaining or increasing health care quality. Mr. Mechanic and Dr. Altman really like the idea because 1) multiple payment and delivery models can be simultaneously tested "without administrative or judicial review," (that's on page 725 of the Senate bill), 2) immediate budget neutrality is not necessary (page 722) and 3) the business-as-usual "demonstrations" to test innovations would be replaced by "pilots."

This is where the DMCB got confused. Section 3021 of the Senate's "Patient Protection and Affordable Care Act’’ is devoted to the CMI and it appears to direct the Secretary of HHS to test "models" of care. A pdf search found no mention of language that specifically directs the CMI to address 'pilot' programs in lieu of "demonstrations."

So, the intrepid DMCB searched the House Bill and looked through section 1907 on CMI (it starts on page 1198) and likewise found a lot of language devoted to testing "models," but no "pilots."

While you may be tempted to ask "so what?", the DMCB points out that when the Patient Centered Medical Home (PCMH) was included in the House Bill as a "pilot," there was much rejoicing among the primary care organized physician groups. That's because the term "pilot" was widely, if informally, interpreted to mean that it was the intent of Congress to test how, not if the PCMH should eventually be included as a covered Medicare benefit. Ditto Accountable Care Organizations (ACOs) and payment bundling.

According to one statute terminology savvy Washington DC colleague that the DMCB contacted, the current inside-the-beltway-adage is that "pilots fly, while demos die." While that may or may not be consistent with the current proposed legislative language, it appears that while there is less testing oversight, getting a successful pilot implemented into Medicare still literally takes an act of Congress.

Given the 50-50 chance that the term "pilot" could get swept up into law, in turn begetting the generation of countless man-hours devoted to creating favorable regulations from legions of policy makers, academics, grant recipients and other recipients of government largesse, the finicky DMCB conducted an internet search on "pilots" vs. "demos" and found this in a site:

Special projects that test improvements in Medicare coverage, payment, and quality of care. Some follow Medicare Advantage rules, but others don't. Demonstrations are usually for a specific group of people and/or are offered only in specific areas. There are also pilot programs for people with multiple chronic illnesses designed to reduce health risks, improve quality of life, and provide savings (bolding from the DMCB).

While readers are probably thankful for that helpful clarification, it gets worse. Here's a pair of articles that point out that it don't matter what you call 'em: demos as well as pilots seem to be equally vulnerable to bungled execution by the Administration and being politically disavowed by Congress.

After reading all of this, the DMCB can't decide if the difference between "pilots," "demos" or even "models" is informally cosmetic, intentionally vague or is based on some deeper set of regulations, case law or assumptions that are only grasped by a few insiders. If there isn't a real difference, the DMCB doesn't understand why legislation that heaps billions more on CMS for what could be more of the same old same old is any cause for celebration. Labeling it with the term "Innovation," sprinkling it with less oversight and adding a dash of cost-savings flexibility stands little chance of overcoming Medicare's entrenched mainframe culture and Congress' addiction to political expediency.

Based on the information above, a newfangled Center for Medicare and Medicaid Innovation hardly represents the kind of breakthrough that is being represented by reform advocates or in the New England Journal of Medicine.

Unless the DMCB has this wrong. Does it?

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