Health Care Reform is promoting CMS demonstration and pilot projects to reduce costs and improve the quality of health care. In fact, these projects are so central to the recent health reform legislation that demonstration is mentioned 312 times and pilot 80 in the text of the bill.
Many demonstrations have been ongoing but have been expanded in scope or extended in duration and these are joined by several new initiatives. All of these program aim to create accountability and to change physician and hospital behavior. The attempts at bundled payments, gainsharing and episodes of care have already demonstrated that they have the desired effect, especially when it comes to the use of testing and in the selection of drugs and devices. Attached below please find a list of all the pilots and demonstrations discussed in the Patient Protection and Affordable Care Act (H.R. 3590), followed by a brief discussion of some of the initiatives that will have the most impact on hospital and hospital related physician services and their formulary and testing choices.
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 (rehab)
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
Sec. 3023. National pilot program on payment bundling
A pilot program to develop Episodes of Care (EOC) around a hospitalization. The applicable conditions shall be selected by the Secretary and must include a mix of chronic and acute conditions where an opportunity exists to improve quality of care and which show variations in the number of readmissions and the amount of expenditures for post acute care. The selected conditions must also involve high volume and high post acute care expenditures and are amenable to bundling. The bundle would include inpatient, physicians’ services in and outside the acute care hospital setting, and post acute care services. The EOC would extend from 3 days before admission to 30 days following discharge. This pilot must be implemented by Jan 1, 2013. Quality measures shall be created in conjunction with AHRQ for the EOCs and for the follow up post acute care. The measures need to include functional status improvement, rates of discharge to the community, rates of admission to an ER after hospitalization, HAIs, efficiency, patient satisfaction, and outcomes. Payment can be through bundles and based upon bids from entities for each EOCs.
Section 10308 Revisions to National Pilot Program on Payment Bundling
After Jan. 1, 2016 the Secretary may expand the duration and scope of the pilot program.
Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers
Pilot program shall be established not later than January 1, 2016 to test the implementation of value based purchasing program for psychiatric hospitals, long term care hospitals, rehab hospitals, PPS exempt cancer hospitals, and hospice programs.
Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization
Establish a demonstration to evaluate bundled payments for integrated care during a hospitalization which includes concurrent physician services, commencing January 1, 2012 to Dec. 31, 2016. This shall be rolled out in up to 8 States, and they may target particular beneficiaries, conditions, or geographic regions.
Sec. 2705. Medicaid global payment system demonstration project
Move a safety net hospital system or network from a fee for service to a global capitated payment model. This demonstration shall operate from 2010 through 2012 in 5 states.
Sec. 2706. Pediatric Accountable Care Organization demonstration project
A demonstration program from Jan. 1, 2012 through Dec. 31, 2016 which shall allow incentive payments for the creation of pediatric ACOs. There will be performance guidelines established and must show savings. The ACOs that meet the performance guidelines and achieve savings greater than the annual minimal savings level shall receive an incentive payment as a portion of the amount of such excess savings.
Sec. 3027. Extension of gainsharing demonstration
Extends the current demonstration.
Sec. 4204. Immunizations
States may enter into contract negotiations with manufacturers of vaccines for the purchase and delivery of vaccines for adults. The Secretary shall set up a demonstration to award grants to States to improve the provision of recommended immunizations for children, adolescents and adults. These funds shall pay for reminders, education, reducing out of pocket costs to families, promote immunization strategies, home visits to promote immunizations, provide reminders and assessments of immunizations to providers. The GOA shall conduct a study by June 2011 on the number of Medicare beneficiaries who received routinely recommended vaccines.
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