Testing States

Colorado

Click Here for Updated State Plan
State's SIM website

  • Project total cost of care savings of $126.6 million over the course of the SIM program, with annual savings of $85 million thereafter to help sustain Colorado’s model. (p.1)
  • A Health Transformation Investment Fund will provide early incentives to both payers and providers as they make the necessary changes toward integrating behavioral health and primary care, both financially and clinically. (p.18)
  • Colorado proposes to use one-third of actuarially projected savings to support ongoing activities related to the project. We also anticipate that changes in payment models will become permanent and ongoing after the grant period. (p.19)
  • Aligning provider payment with financial outcomes (total net reduction in healthcare costs) is a key element of our proposal. Goal is by 2019 (fourth year of the SIM grant), payers serving a majority of Coloradans will reimburse practices for integrated physical health and behavioral health services in shared risk and savings programs. Furthermore, a significant number of integrated practices will receive a global or capitated payment for comprehensive primary care. (p.19)
  • Colorado has received firm commitments from six private payers to:
    -Continue care coordination payments;
    -Move to shared savings opportunities;
    -Move to prospective, non-volume payments;
    -Use the SIM minimum data set; and
    -Support the aggregation of clinical and claims data.
  • The cornerstone of this payment reform glide path is the readiness and ability of primary care practices to move from a fee for service environment. This approach contemplates a gradual transition to new payment models that allows for long-term adaptation, rather than an immediate switch that could result in market instability. (p.25)
  • Example of reforms (p.33) and descriptions of phases. (p.28-29)
  • Grant Budget and Narrative (p. 75)
  • Colorado’s SIM most closely resembles the PCMH payment model, rather than the ACO model, and aligns with the CPCi approach to payment reform. (p. 22-25)

Connecticut

Click Here for Full State Plan
State's SIM website

  • Many innovative approaches are mentioned in the proposal including state funding, assessments on insurance carriers/payers, wellness trusts, innovative Medicaid and possibly commercial insurance reimbursement policies, payments by entities such as hospitals and payers which derive benefit from community prevention. (p.3)

Delaware

Click Here for Full State Plan
State's SIM website

  • Attribute all patients to primary care physicians (PCPs) and incentivize PCPs to address specific measures (obesity screening, smoking, diabetes control) as well as total cost, Delaware’s payers are shifting incentives to support population health. (p. 3)
  • Transition to value-based payment models that support integrated care delivery - create flexibility for many different types of provider organizations to participate in new models, allowing providers to innovate how they integrate with organizations focused on improving population health. (p.7-8, 14)
  • Population Health and Common Provider scorecards – align measures so that providers and community organizations have common areas of focus (p. 8); align measures across payers (p. 18)
  • All payers introduce one Pay for Value (P4V, with bonus tied to quality and utilization management for a panel of patients) and one Total Cost of Care (TCC, with shared savings linked to quality and total cost management for panel of patients) payment model option to eligible PCPs (p. 17-18)

Idaho

Click Here for Full State Plan
State's SIM website

  • Align payment mechanisms across payers to transform payment methodology from volume to value. Idaho’s 3 largest commercial insurers in the State will participate in the model: Blue Cross of Idaho, Regence BlueShield, and PacificSource. Together, these three payers account for approximately 92% of the individual market, 95% of the small group market, and 97% of the large group market. (p. 6)
  • Financial analysis indicates that Idaho’s healthcare system costs will be reduced by $89M over 3 years through new public and private payment methodologies that incentivize providers to focus on appropriateness of services, improved quality of care and outcomes rather than volume of service. (p. 7)
  • Idaho projects a ROI for all populations of 197% for five years. (p. 7)
  • Idaho’s Model Test both drives and supports the transformation to the new delivery system by utilizing grant funding to support start-up costs for PCMH transformation, and to incentivize higher levels of PCMH recognition. Payer-provided PMPMs and shared savings payments will cover the practice costs associated with ongoing care coordination and patient management, as well as the costs of collecting quality and performance measures. (p. 7-8)
  • The new payment model components will include Per Member Per Month (PMPMs) payments to support care coordination and other PCMH functions, total cost of care shared savings arrangements, and quality incentives. (p. 9)
  • PCMH Practice Transformation Incentives & PCMH National Recognition Incentives. (more details p. 10-11)

Iowa

Click Here for Full State Plan
State's SIM website

  • Iowa has expanded Medicaid through the Iowa Health and Wellness Plan (IHAWP), which began on January 1, 2014, and provides comprehensive health care coverage to low-income, uninsured Iowans ages 19 to 64.8 Part of the IHAWP is the Healthy Behaviors Program, which emerged as a SIM concept during the SIM Design and incentivizes all IHAWP members to work with providers to be healthy and stay healthy. Members who achieve the Healthy Behaviors requirements will not be responsible for a monthly premium. Medicaid has designed payment levers for both the primary care provider and the IHAWP ACOs that align with the member healthy behaviors. (p. 4).
  • Development of multi-payer ACOs is a key driver of system transformation. Iowa's delivery system is characterized by a relatively small number of large entities that already work together, including several large health systems that deliver the majority of acute care services and employ more than half of the primary care physicians. This multi-payer foundation creates a powerful opportunity to align accountable pay-ment structures to enhance providers’ ability to achieve critical mass and catalyze transformation. (p. 8-10)
  • Currently, one commercial payer is committed to participating in this payment model, Wellmark, which accounts for 41% of the Iowans who are covered by commercial insurance. (p. 14)
  • A value-based payment model closely aligned with Wellmark and similar to Medicare is a key strategy in Iowa’s SIM. See table with keey components of payment structure in full Medicaid ACO (p.14). The State is also open to testing payment reform pilots such as partial and full capitations for ACOs that prove effective at transforming them into a value-based entity. (p. 15)
  • IME, in conjunction with Wellmark, will work with Treo Solutions to develop, simulate, and test the appropriate and most effective way to embed incentives that will further drive ACOs to invest in the required tools, capability, and capacity to address SDH without increasing risk avoidance. (p. 17)
  • For the state-wide Medicaid ACO strategy laid out in this proposal, DHS intends to submit a Payment Methodology State Plan Amendment (SPA) to CMS and move Medicaid into a 1915(b) waiver for choice and PCP assignment. In addition, the State will leverage ACO con-tracts to expand the ACOs into a community setting with a population health focus (p. 26).

Michigan

Click Here for Full State Plan
State's SIM website

  • Payment Service Delivery Models : Patient Centered Medical Homes, Accountable Systems of Care, and Community Health Innovation Regions. (p.7-11)
  • Patient Centered Medical Home transformation is well underway in Michigan. (p.7-11)

New York

Click Here for Full State Plan
State's SIM website

  • Beyond SIM funding, sustainability to be derived by: payer contributions as the value of vices is recognized (ex: tobacco cessation), ongoing support through the new Medicaid waiver, and hospital community benefits. (p.3)

Ohio

Click Here for Full State Plan
State's SIM website

  • As part of SIM Design Process, achieved multi-payer agreement across Medicaid, state employee, and commercial health plans to launch episode-based payments statewide in November 2014. (see abstract).
  • Ohio adopted a goal to enroll 80-90 percent of the total population in value-based payment models that support health care delivery system transformation. (p. 7)

Rhode Island
State's SIM website
Click Here for Full State Plan
  • The first Population Health Plan vendor will be responsible for the overall development of the plan, working with the Healthy Rhode Island Steering Committee to assess the overall health of the state and identify measurable goals, objectives and interventions. This vendor will also be tasked with monitoring and evaluating our progress in meeting those goals. We have allocated $750,000 for this work.(p. 4)
  • We will hire a second vendor who will be responsible for ensuring our Population Health Plan explicitly recognizes the behavioral health needs of our residents. This vendor will also assist in the implementation of the transformation of our behavioral health system, in concert with our overall healthcare delivery transformation. We have allocated $750,000 for this work. (p. 5)
  • This grant proposal seeks funding in two areas to support the transformation of our health care delivery system. The first is through explicit funding for new models of care or enhancements to existing models that are already alternatives to a volume-based delivery of care. We have allocated $4.6 million towards this effort. We are also proposing to use $6.8 million to support our Health Information Infrastructure. (p. 7)

Tennessee

Click Here for Full State Plan
State's SIM website

  • PCMH model will have menu of payment options for providers and payers to agree upon. (p. 6)
  • Principal Accountable Providers (Episodes of Care) – rewarded for high quality and efficient care across the episode, shared savings when patients receive high-quality, efficient care (or in excess costs in care is above average). (p. 9)
  • Value-based purchasing for enhanced respiratory care. (p. 12)

Washington

Click Here for Full State Plan
State's SIM website

  • State will be "first mover" to shift 80% of the market from fee-for-service to value-based integrated payment models by 2019. (see chart, p. 13)
  • The 10 prototypes for ACHs were financed with $485,000 in State funds but need SIM funding to fully implement. The proposal is earmarked ~$3.2 mil/year X 4 years for ACHs (see p.4 of Operation Plan). Medicaid payment to be reorganized around the 10 ACH regions. Medicaid contracts will require coordinated care, case finding, patient engagement and community linkages. Reimbursement to Federally Qualified Health Centers and Rural Health Centers will shift from fee-for-service. (p. 21)
  • Puget Sound area public employees' benefit plan to become an accountable delivery model in 2016. (p.12)

Design States


American Samoa

More to come...

Arizona:
Click Here for Full State Plan
State's SIM website

  • Enhancing capacity for payment reform among integrated and behavioral health providers by increasing access to data and providing funding to accelerate organizations’ ability to enter into modernized payment structures, which will extend to non-Medicaid/Medicare lines of business as experience grows. (p. 13).
  • Arizona Health Care Cost Containment System (AHCCCS) will ensure competitive incentive payments that reward high performance. (p. 15)
  • Implement multi-payer, value-based payment reform programs to align incentives toward high quality, cost-efficient health care and improved population health. (p. 30)

California

More to come...

District of Columbia

More to come...

Hawaii:
Click Here for Full State Plan
State's SIM website

  • Payment and/or Service Delivery Model, transitioning from a fee-for-service payment system to a model based on outcomes. (p. 9)

Kentucky
Click Here for Full State Plan
State's SIM website
  • KY Medicaid initiative to begin January 2015 to increase reimbursement rates for certain high-value prevention services that have been demonstrated to provide a strong ROI. (p. 9)
  • Kentucky has identified four broad goals for payment reform: 1) Incentivize Greater Prevention to Improve Population Health Outcomes, 2) Improve Chronic Disease Prevention & Management with Innovative Payment Models, 3) Incentivize Adoption of Integrated and Coordinated Care Models, 4) Align Payments with Quality of Care. (p. 9)

Illinois
Click Here for Full State Plan
State's SIM website
  • Integrated delivery systems will be evaluated on both their current state of progress toward, and their ability to achieve during the Model Test period, the following characteristics: Financial plan: costs for target population reduced to equal/exceed pilot funding; Multi-payer: direct contract with the State, commercial plans and Medicare; and Provider incentives: Distributes outcomes-based payments, rewards efficiency. (p. 8)
  • By the end of 2016, the integrated delivery networks developed through participation in the Pilots, will have begun covering Medicare enrollees and be ready to begin contracting with commercial health plans. Illinois’ Model is designed to ensure that patients moving between Medicaid and commercial coverage experience minimal disruptions in care and have access to the same effective, highly integrated delivery networks regardless of their health insurance coverage. (p. 10)
  • Tested payment reforms will include: Patient-Centered Primary Care Home (PCPCH) payments; Bundled payments, including case rates, fee-for-service (FFS) with risk-sharing, and episode payments; Risk and gain-sharing arrangements; Service agreements aligning incentives for specialty and primary care physicians; 11 Quality bonuses or other performance incentives; and Coverage of non-medical services. This may include bonuses for stable housing, removing allergens from the home of an asthmatic person or helping individuals with disabilities prepare for employment. (p. 11)
  • Through the work of the Integrated Delivery System Reform subcommittee, on which health plans and providers participate, the Model Test will align the Pilot measures and targets with commercial health plan value-based payment structures. (p. 12)

Maryland:
State's SIM website

More to come....

Montana

More to come...

Nevada
Click Here for Full State Plan
State's SIM website

  • Payments to providers and/or service vendors are tied to value and performance that lead to better controlled costs. (p. 5)
  • DHCFP is continuing to collaborate with payer and health care systems across the state. This work effort will identify additional populations that may be addressed by this initiative. Based on an initial assessment of the potential payer system collaboration, we have identified the potential population target groups as the following: Medicaid, CHIP, Indian Health Services (IHS), Public Employees Benefit Plan (PEBP), and the Culinary Unions Self-Funded Plan. This target population includes approximately 700,781 beneficiaries, or 25 percent of the State's population. Nevada is encouraging commercial plans to participate as well and will continue toward that goal. At this time, we are not considering Medicare population participation, but we are open to reconsidering if desired by CMS. (p. 8)
  • DHCFP is committed to designing a state health plan that includes multi-payer payment innovation and measure alignment. (p. 11)
New Hampshire:
Click Here for Full State Plan
State's SIM website

  • Improvements in communication and IT will improve the dynamic of health care delivery and decrease pre-capita health care spending. (p. 3)
  • Payment and/or Service Delivery Model includes discrete payment methodologies, expanding Medicaid and other strategies that will result in short, medium and long-term cost savings. (p. 8-9)

New Jersey

More to come...

New Mexico
Click Here for Full State Plan
State's SIM website

  • New Mexico will use grant funds to explore development of a community paramedicine program to support health promotion and disease management. (p. 6)
  • NM is reducing reliance on high-cost services through improved disease management programs, greater use of health information technology, and new payment models that focus on effectiveness and efficiency (p. 5).
  • New payment models are expected to complement the PCMH initiative and Centennial Care innovations. These innovations include an array of payment options that can work within the capitated payments made to the Managed Care Organizations (MCOs), but will also be applicable for payers and systems outside of Medicaid. New Mexico Medicaid is in the early stages of piloting several payment reform models, including bundled payments, pay-for-performance, shared-savings models, and payments for episodes of care. (p. 6)

Commonwealth of the Northern Mariana Islands

More to come...

Oklahoma
Click Here for Full State Plan
State's SIM website

  • The OSIM will engage and strategize with private businesses and public and private payers to develop a health system transformation plan that targets value-based insurance design. (p. 8)
  • The OHIP Coalition will also align and leverage existing innovative payer efforts that are ongoing. For example, the OSIM plans to leverage and align efforts with the Comprehensive Primary Care (CPC) initiative, which includes Blue Cross Blue Shield of Oklahoma (BCBSOK), CommunityCare of Oklahoma, and the Oklahoma Health Care Authority (OHCA), as well as OHCA’s Health Access Networks (HANs) and Patient-Centered Medical Homes (PCMH) initiatives. (p. 17)
  • Healthcare Financing Workgroup – will work with the actuarial contractor to integrate state-purchased insurance into a new value-based payment model and pay-for-success, and perform actuarial analysis of OSIM interventions and ROI evaluations. (p. 28)

Pennsylvania
Click Here for Full State Plan
State's SIM website

  • The Department of Public Welfare (DPW) will hold contracted insurers accountable for advancing alternative payment models including Accountable Provider Organizations (APOs) and PCMHs in order to drive outcomes-based performance. In Years 1 and 2, DPW will advance its value-based payment models with the Medicaid managed care and new waiver eligible population. In Year 3, these initiatives will be expanded to dually-eligible consumers, including aging waiver participants. (p. 10-11)

Puerto Rico

More to come...

Utah

More to come...

Virginia

More to come...

West Virginia
Click Here for Full State Plan
State's SIM website

  • Table 1 (p. 2) illustrates the distribution of two subgroups of the WV population that experience multiple chronic conditions and have the greatest impact on the health care system. Tier 1 targets the highest cost beneficiaries; Tier 2 is comprised of the larger segment of the respective coverage groups with chronic conditions or other “modifiable” conditions that result in avoidable costs or utilization of health care services. The target of this model design is to focus on these tiers as high cost and impactable populations and then generalize to a broader patient population. (p. 2)
  • The design team will continue to work with representatives of Medicaid, CHIP, Public Employee Insurance and participating commercial and managed care payers through the Collaborative and other initiatives to coordinate the alignment of payment models with the health care transformation plan. Our intention is to encourage the phased progression from the current fee-for-service and cost-based reimbursement model to a value-based compensation arrangement. (p. 8)
  • The target of the model design is to start with high cost and impactable populations based upon claims analysis and then spread to a broader patient population. This is consistent with the approach taken by the WV Medicaid program in launching the health homes project and by Public Employees Insurance Agency (PEIA) and Highmark WV in implementing and incentivizing PCMH models. (p. 8)

Wisconsin

Click Here for Full State Plan
State's SIM website

  • The DHS and the SVC LC will engage providers, payers, purchasers, and consumers across the state to assess priorities for payment models to support the targets for care delivery transformation identified under the process described in § (2). Wisconsin will build on existing payment models and experiments in the state (e.g., public designation of centers of value, pay-for-performance, expansion of risk-based contracting, bundled payments for acute procedures, reference pricing, Medicare and private sector accountable care organizations [ACOs]). Wisconsin’s strategy will be to choose highest priority areas of care delivery redesign (described in § 2), and develop payment strategies to support sustainable, cost-effective, equitable improvements in care. Wisconsin will seek to align with ongoing and emerging Medicare value-based payment strategies to ensure that the state has a pathway to reach the target of 80% of payments from all payers in value-based alternatives to fee-for-service. (p. 6-7)
  • Wisconsin has ensured access to coverage for all residents through a waiver covering childless adults up to 100% FPL, with those above 100% FPL receiving care in the federal Health Insurance Marketplace. Medicaid now covers approximately 17% of the state’s population. Stakeholders participating in the SVC touch the preponderance of providers and members across the state to reach the target of 80% of payments through value-based arrangements. (p. 7)
  • Examples of models that will be reviewed include tying payments to outcomes (value-based payments), examining Medicaid health home payment models, and using incentive payments to promote the adoption of electronic health records (EHRs) and health information exchange (HIE) for providers not eligible for meaningful use payments and/or implementation of best practices. (p. 8)