One of the biggest criticisms of any health reform package, particularly the latest one from the House, is the lack of concrete cost containment provisions.
However, a read through the bill's 1,990 pages finds a number of novel proposals that seek to test new ways of measuring and monitoring care.
With these projects, the secretary of Health and Human Services, perhaps through the granting of Medicare waivers, would try out a few ideas that might make the healthcare system not only produce better outcomes, but also become more cost-efficient.
"There's a lot of interesting ideas and pilot projects" in H.R. 3962 says Robert Laszewski, president of Health Policy and Strategy Associates of Washington, D.C. He adds the administration is proposing many such programs "because we're really not sure yet what is going to work."
Here are five such demonstration or pilot projects—most set up for only two or three years—geared to contain costs:
- Post-Acute Care Services Payment Reform Plan and Bundling Pilot program. This program is designed to reduce hospital readmissions by "bundling" payments to skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals, hospital-based outpatient rehabilitation facilities, and home health agencies that care for a patient after hospital discharge. Many of the specifics, however, have yet to be defined.
- Accountable Care Organization Pilot Program. This project would test ways to incentivize providers, perhaps through monetary awards, to physicians to provide quality care, more efficiently, and at a lower cost.
- Medical Home Pilot Program. Under this provision, states would be entitled to apply for pilot project grants to give comprehensive care and case management to patients with chronic illnesses, including medically fragile children and high-risk pregnant women. This program also could be used to test wireless technologies that allow practitioners to communicate directly with their patients in managing chronic illness and thereby reduce expensive, acute hospitalizations.
- National Independent Monitor Pilot Program. This project is perhaps the most novel and bold. The administration would appoint an independent monitor to "oversee" large chains of skilled nursing facilities for some defined period of time.
These companies would submit applications to the administration if they wanted to be included, but their selection would be approved when "evidence suggests that one or more facilities of the chain are experiencing serious safety and quality of care problems" presumably those that result in a decline in quality and an increase in cost of that care.
These participating companies would, by contract, allow an independent monitor to "conduct periodic reviews and prepare root-cause quality and deficiency analyses of a chain to assess if facilities of the chain are in compliance with applicable laws. The reviews would be published.
- Independence at Home Demonstration Program. This project would test a way of rewarding physician, nurse practitioner, and pharmacist teams to visit the homes of severely ill patients with chronic diseases on a 24/7 basis. The goal would be to improve health outcomes and keep patients from rushing to the emergency room.
The teams would be paid a set rate per beneficiary, but would be rewarded with any savings they achieve, not unlike a capitated model.
Those teams selected for such a pilot demonstration project would also use electronic health information systems and remote monitoring, as well as mobile diagnostic technology, all of which can function more efficiently and less expensively than the traditional acute care setting.
Though these five programs are in the latest House health reform bill, many critics have charged there still isn't enough concrete cost savings in the legislation. Plus, many questions remain:
- If the bill passes with these proposals intact, which will be picked for these short-run demonstration projects?
- Who will decide if they actually work?
- How much will it cost to test them and will those involved be strong enough to admit when they have failed?
- If the projects do work, how can they be effectively expanded, and who will have the authority to decide?