Putting State Innovation Model (SIM) dollars to work

Margot Thistle with research assistance from Alli Dorneo

The SIM initiative seeks to advance and accelerate state delivery system and payment reform efforts.  Under Section 3021 of the Affordable Care Act (ACA), SIM grants may be awarded to states and territories that demonstrate a comprehensive plan that transforms the delivery system, aligning with the “triple aim” objectives of reducing costs, improving quality, and population health.

To date the Centers for Medicare and Medicaid Innovation (CMMI) has issued a total of 38 SIM awards to 34 states, three territories, and the District of Columbia, for model design and testing. The initiatives underway in SIM grant models touch 61% of the population.

These awards are broken into:

Round 1 -- totaling over $250 million, and includes Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont;

Round 2 -- totaling over $660 million, and includes Colorado, Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Ohio, Rhode Island, Tennessee, and Washington.

The above awards include both test and design models; with test models allowing states to implement strategies for transformation that meet the state specific health needs, and design models allowing states to plan the transformations needed to meet state specific health needs. 

Applications for Model Testing, the highest stage of SIM Implementation, feature state-specific plans that enhance care coordination, the integration of services, value-based care, quality measures, the health care workforce, as well as health information technology and infrastructure. Given the focus on multi-payer payment models and delivery systems, applications must also demonstrate strong external and governmental support from a variety of stakeholders that include public and commercial payers, providers, and consumers. We have included additional information on two model testing projects currently underway in Vermont and New York--with additional insights from our work with New York on the Delivery System Reform Incentive Payment Program (DSRIP). 

Vermont SIM/Health Care Innovation Project
Vermont was selected in 2013 as a Round 1 model testing project, with $45 million allocated for the Health Care Innovation Project (VHCIP). The VHCIP focuses on the restructuring of payment models, care delivery models, and health information systems as key components of achieving the triple aim in health care. 

After substantial investments in a regional practice transformation, VHCIP experimented with a variety of value-based payment models including Accountable Care Organization (ACO) Shared Savings Program, medical homes (Blueprint for Health), pay-for-performance program, and an all player model ACO model. This year, the VHCIP will continue working under these alternative payment models, while considering how to set the precedent for the All-Payer ACO Model that is underway.

Vermont recently concluded the third performance period, and finalized the SIM Sustainability Plan, which outlines long term planning for “SIM-funded” activities and improved community health following the end of the grant in June 2017. One step VHCIP has taken to ensure program sustainability is the development of regional and community learning collaborative with core-competency trainings aimed to educate providers on reform initiatives and quality improvement.

Another priority of the VHCIP’s sustainability plan is to improve the health data infrastructure to enhance the sharing capabilities and coordination between providers and the creation of an inventory with comprehensive, high quality health data. SIM has already engaged an additional 400 providers in an effort to direct their electronic medical records to a larger Health Information Exchange (HIE). As is the case in many states, Vermont has spent years replacing and improving existing infrastructure in order to support alternative payment models and quality measurement initiatives within VHCIP and other ongoing policy reforms. The efforts to modernize the HIE in Vermont continue, with interface between hospitals, primary care, home health, long term care and labs aimed to improve the quality of healthcare for Vermonters. 

New York SIM/Advanced Primary Care 
In 2014, New York received $99.9 million from CMMI, the largest SIM grant awarded to date, for model testing of the Advanced Primary Care (APC) plan. Similar to VHCIP, APC’s goal is to transform the system’s payment models, technical infrastructure, quality measurements, and workforce capacity-specifically among small primary care practices. This goal requires the development of APC scorecard measures, a definition of the value-based payment model, aligning key stakeholders in this multi-payer system, and delivering the materials and resources to participating providers. 

Additionally, New York has worked on creating the infrastructure primary care practices will need to implement the reform efforts. As of 2017, New York released the APC contracts for eligible practices and outlined the metrics and milestones expected to improve over the course of the program. The quality measures featured on the APC scorecard have a strong focus on population health outcomes and span several categories including substance use disorder, behavioral health, preventive services, and appropriate hospital use. The range of categories and services offered are intended to encourage integration and coordination among providers. Early data collection on a select group of measures is already underway and by late 2017, full practice transformation should be complete. 

Many of the APC quality measures and goals align with New York’s DSRIP and together the two programs work to move 80% of payments toward value-based care by 2020. APC also aims to provide 80% of the population with care from an integrated care model. As parts of APC begin to come into full functionality this coming year, the monitoring and evaluation of the practices’ progress will be crucial in determining whether further modifications will need to be made to the information databases, scorecard measures, payment structure, or workforce expansion groups.  

By 2018, New York is expected to accumulate gross savings of $4.4 billion between the APC program and other ongoing delivery system reforms. For more on PCG’s work with New York on DSRIP, click here.