Let Me Demonstrate…
There are many provisions in the Affordable Care Act that people don’t know about. Everybody is familiar with the health insurance part of it, but did you know the Centers for Medicare and Medicaid services (CMS) is giving $10 billion dollars to an organization called “The Innovation Center”? The Innovation Center is charged with researching ways to most effectively deliver health care. Good goal. The center’s website says “The Innovation Center develops new payment and service delivery models”. Oh. Well, still good goal.
Here’s what the definition of a “model” is, according the the free online dictionary: A schematic description of a system, theory, or phenomenon that accounts for it’s known or inferred properties and may be used for further study of its characteristics. So a model is not the thing. It’s a smaller or schematic representation of the thing. So what the Innovation Center is supposed to do is find or come up with schemes of payment and service delivery and try them out. It has been doing this, so far, largely with “demonstration projects”. A demonstration project tests an idea or group of ideas that might improve either payment systems or delivery systems, and then uses some complicated math to determine if things were better or worse before and after the idea is implemented. Therefore, CMS is not looking for proven methods of improving payment or services, but testing ideas that might work.
There’s nothing wrong with this, by itself. My 2-year-old does this all the time. She peers up at the kitchen counter, determines she can’t see, drags a chair over, gets on it, and compares the view with the chair vs. the view without the chair. Over time this has allowed her to develop a policy of always getting a chair if she wants to see what I’m doing. She wouldn’t go get the chair if I just said “be a good girl and go get a chair” and then praise her and give her a cookies if she does it. If you go the the Innovation Center website what you mostly see is incentive programs for good behavior. For example: The Comprehensive Primary Care Initiative is one of the Innovation Center’s projects. This is how CMS describes this program:
“The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients.”
Here’s another: The Physician Group Practice Transition Demonstration:
‘The PGP Demonstration was the first pay-for-performance initiative for physicians under the Medicare program. Under the PGP Demonstration, physician group practices continued to be paid under regular Medicare fee schedules, but earned incentive payments for offering patients high-quality, coordinated healthcare that resulted in Medicare savings for the patient population they served.”
Another, the Medicare Health Care Quality Demonstration, goes straight to performance measures. Three hospital/physician care systems in the US are being given money to test ideas that will improve performance measures. Performance measures are not “performance” measures. They are “quality” measures. Doctor’s get up on stage and perform certain things, and judges evaluate whether their performance is a quality one. As I have said before, measures of quality are things that are easily measured, quantifiable, and easy to find in an electronic medical record.
OK, to summarize so far: CMS, i.e the federal government, is funding the Innovation Center, which is supposed to find better ways to pay for and deliver health care, but which is mostly doing pay-for-performance stuff. Fine. There are some people doing some fine work in health care delivery who could use the funding. Some people are complaining that all the studies that the Innovation Center are doing are demonstration studies, not randomized controlled trials (RCT). RCT’s are the medical gold standard for proof, essentially. It’s not true until an RCT says it is. Why isn’t the Innovation center doing more RCTs?
I postulate several reasons: 1. RCTs take a lot of time. CMS, under the gun from ACA opponents, wants quicker results. 2. A good RCT has a very narrow research question, usually one or maybe two interventions compared to no change. The researchers have to settle on a promising intervention and follow it up long-term. It’s hard to decide what promising intervention is going to give the best results given how long the question will take to answer. 3. There are so many moving parts in health care. It’s very hard to control for everything. Some large RCTs that have affected national policy, such as the Tennessee study in the 1980’s, which found that smaller class sizes in early childhood translated into better long-term outcomes, changed only one variable and kept everything else the same. Tennessee public schools are a closed system with relatively little short-term variability and relatively predictable human behaviors. An RCT that, for instance, studies the effect of a specific intervention on re-admission rates to hospitals has to deal with the variability of disease process and progression, human behavior, emergency situations, dubious quality measures, record-keeping inconsistencies, the list goes on and on. 4. CMS is a political animal. Politics and RCTs do’t readily mix.
So, should the Innovation Center be doing RCTs? Absolutely. Is CMS funding the way to get that done? Probably not. But you have to give the ACA an A for effort on this one. Hopefully the demonstration studies will demonstrate that one or two of the ideas are worth pursuing with an RCT.