Innovation Challenged Grant

Part of the Accountable Care Act legislation established a new department within HHS' Center for Medicare and Medicaid Services (CMS) - the Center for Medicare and Medicaid Innovation (CMMI).  Ten billion dollars were earmarked for the funding of 'innovative solutions' to healthcare reform.  Many people (myself included) believed that CMMI was created to try out newer more high risk alternatives to reform while the band-aid solutions provided by other parts of the ACA bought time.   Allegedly thousands of experts and innovators were interviewed to get a sense of what was out there on the horizon. 
About half the money was spent on low hanging fruit projects that are not particularly innovative but at least had some successful precedent.  If you look over their website you can see the projects they funded.   If you can't quite figure how some of those projects would ultimately change the game all that much, well you aren't alone.
Nevertheless, the promise still remained.  CMMI announced a 1 billion dollar grant for the most innovative projects it could find - the widely anticipated Innovation Challenge Grant!  This was the announcement that a lot of people had been waiting for.  The program announcement was bold and it looked like they were finally looking for moonshots.  More than 3000 applications representing 10,000 or so organizations applied.  Some of the best and brightest people in the country were involved.

Applicants were  given 40 pages of double spaced text - to explain how they would change healthcare, save billions, train new kinds of clinical providers, and restructure the healthcare system - in 6 months or less.  CMMI promised to review all the applications in record time.  This left few people who weren't applying to review the submissions and little time to dive into the details. The first inclinations of trouble was when they announced that an NIH style of review would be used but with a turnaround of weeks not the usual months. 

About 700 applications were quickly rejected - probably because they messed up on some draconian formatting requirement that is often used on government grant applications.  The announcement date came and went.  CMMI announced that they would have to extend the review dates, a couple of days before it was scheduled.  Presumably it came as a surprise 2 days before the deadline that they weren't yet done. 

A lot of people defend and argue against the way NIH conducts its peer reviewed grant evaluations.  Some people claim its the best and most honest mechanism for identifying promising projects and others accuse it of being little more than anonymous academic cronyism.  The truth, like most things, is a little of both.  It does appear with some regularity that a lot of the same people seem to be getting grants to do a lot of the same things they did before.  Personally, I think the anonymity is a mistake.  Too often, success comes down to the luck of the draw - who gets assigned the initial review.  If they don't like it, well then you're toast.  I reviewed one submission before it went in.  When I was shown the terse and condescending review notes they got back, it was clear to me that at least two of the reviewers hadn't read the proposal very carefully.   Mitigators to their damning criticisms had been well described in the paper.  And in one instance they clearly had not studied the model at all.  Snark in peer review is poor form in my opinion, but particularly so when one does a slipshod job of review.  You won't hear much carping about this sort of thing usually.  People are afraid of ticking off the powers that be so that future grants are at risk.

But what about the innovation challenge?  CMMI announced the winners to great fanfare.  You should go look at their site and see what they thought were the most innovative projects of the 3000.  Most of my colleagues were disappointed.  One went so far as to say that he must have misread the original announcement - he said it must have really said Innovation challenged...

No doubt there are some good projects in there but none is a moonshot by a long shot.  None will control costs to the degree required for the long term.  Some of the claims for cost savings proposed by some of these projects are pure fantasy.  The most technically sophisticated project is using technology that was new 15 years ago.  Most of the money went to large academic centers and health systems - you know, the ones that spend all the money now ;)  I may be wrong but I suspect it will be a huge missed opportunity.    I can see spending most of the CMMI money on more easily obtainable goals, but wouldn't it have been nice if some part of it had been pointed at the moon?

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