SIM: Driving innovation

Sunday, September 01, 2013 12:16 PM

Crafting a strategic road map for health care payment and delivery

Kate Alfano, CMS contributing writer

Colorado has received federal funding to develop a proposal for transforming the state’s health care payment and delivery systems. The Colorado Health Care Innovation Plan, once completed, will be submitted to the federal Center for Medicare and Medicaid Innovation (CMMI) for full funding. The CMS Board of Directors was briefed on the initiative in July.

Last year, CMMI placed a call for proposals for the State Innovation Models Initiative (SIM). States had roughly five weeks to develop and present a plan for state-based health care models that would achieve the “triple aim” of improving population health, improving quality of care and reducing health care costs.

Six states received full approval and SIM grants to begin implementing their plans. Colorado and two other states received pre-testing awards, which allows more time and funds to strengthen their proposals. CMMI indicated that Colorado’s plan should impact a large percentage of the state’s population, reflect a clear vision for payment and delivery system reform, show a strong commitment to multi-payer participation – both public and private – and connect to public health in a meaningful way.

Now, a group of Colorado health care experts – under the leadership of the Department of Health Care Policy and Financing (HCPF) and Gov. John Hickenlooper’s office – have been working with the six-month, $2 million award from CMMI to create a strategic road map that will improve the care experience and population health, and control costs for at least 80 percent of Coloradans over the next five years. It will be submitted to CMMI by Oct. 30.

The key components of the plan include integrating primary care and behavioral health, enhancing coordination, aligning approaches between Medicaid and the commercial payers, and transitioning away from traditional fee-for-service to bundled and global payments for outcomes-based payment.

“A critical piece of our plan will be ensuring the payers and – more importantly – the providers have the glide path to those new models of payment since most physician groups and most hospitals in this state are not yet ready to accept prospective payments and most of our commercial payers are not in a place to begin processing those types of payments,” explained Edie Sonn, vice president of strategic initiatives for the Center for Improving Value in Health Care (CIVHC). “We’re putting together a multi-year plan that is going to transform both delivery and payment.”

She stressed that this is about making changes to Medicaid and in the commercial arena, and that the stakeholders involved in forming the plan are working on models for delivery and payment to align public and private payers. “That’s really crucial for fundamental system transformation. Colorado’s plan is founded on the principle of integrated care, specifically in terms of our model integrating behavioral care more broadly into the primary care setting.” Sonn is serving on the state’s management team responsible for the project.

The rationale
As stated in public SIM overview materials, health care in Colorado is fragmented: delivery systems are not coordinated, individuals are treated in parts rather than holistically and fee-for-service payment does not support integrated care approaches.

“I don’t need to tell any of you the importance of behavioral health and mental health in primary care because I’m sure you all know this better than I,” explained Benjamin Miller, PsyD, assistant professor at the University of Colorado at Denver School of Medicine and director of the Office of Integrated Healthcare Research and Policy (addressing the CMS Board of Directors). “Part of the reason the state decided to pursue this line of clinical inquiry is because of the ridiculous fragmentation that exists between physical and mental health care.”

He explained that, in any given year, roughly 25 percent of patients present with mental health problems. Between 15 and 18 percent of those patients present only to the primary care sector and between 40 and 60 percent of those who are identified and referred to the mental health sector don’t seek treatment. In those terms, he said, primary care is “almost the de facto mental health system,” which leads to the desire to integrate behavioral and mental health with the largest platform of health care delivery, primary care.

The basic concept is to co-locate a mental health provider in a primary care practice to allow the physician and mental health provider to work collaboratively on a shared treatment plan and improve outcomes.

“What’s new here is we have a multi-system approach,” Miller said. Instead of just focusing on the clinical model, which many are currently pursuing, the SIM leaders are focused on building the financial model for long-term sustainability. Miller cited a recent survey that showed that 77 percent of primary care practices that have chosen to integrate care were primarily funding the effort with grants. Other practices have found “creative ways” to be paid for integrating these services that don’t necessarily translate to the majority of health settings.

“That’s a problem,” Miller said. “What we want to do is free up practices to actually pursue these models, irrespective of what the payment barriers are, and give them a fighting chance to continue to do what’s best for their communities.”

Crafting the plan
Refining the proposal requires the work of many health care leaders from around the state in various levels of involvement. It begins with the smallest and most involved group, the SIM management team, which includes core staff from HCPF, the Colorado Health Institute, the University of Colorado School of Medicine Department of Family Medicine and CIVHC. They will conduct research, oversee all stakeholder input and draft the innovation plan.

One level up are the workgroups. The provider workgroup includes primary care physicians, behavioral health specialists and hospital representatives who represent practice needs and clarify workforce implications. The public health workgroup includes primary care physicians, and representatives from local and state public health agencies and consumer groups who are considering models of community-driven systems of care and how to link them around common preventive health goals. A payer group comprising commercial payers and Medicaid are guiding the development of payment models. And the specific populations workgroup considers targeted areas of focus – K-12, homeless and Indian tribes – who will make recommendations based on the needs of their populations.

Moving up another layer is the steering committee, a group of roughly 20 people from the business and health care sectors who will closely examine the work of the workgroup. And finally, the advisory group – a large group of stakeholders that will meet three times over the award period to give big-picture direction as the plan takes shape. The advisory group will approve the final plan. CMS CEO Alfred Gilchrist serves on the steering committee and CMS President Jan Kief, MD, serves on the advisory group.

“There are plenty of opportunities for public input and public comment,” Sonn said. She encourages all to visit the website, www.ColoradoSIM.org, for more information and to view draft versions of the plan as they are available.

Stakeholders hope CMMI will approve the new Colorado Health Care Innovation Plan, and award full federal funding to implement it. However, receiving funding is not paramount.

“We need to fundamentally transform the way we deliver and pay for health care in this state. We need to eliminate the fragmentation; we need to move toward more coordination and integration of care,” Sonn said. “We’re creating enough momentum over the course of these six months with these stakeholder meetings that we will sustain the momentum and keep us moving down this path.”