Friday, September 27, 2013

SIM update -- questions about numbers driving policy

Significant questions have been raised about the methodology and sources for the Sept. 17th SIM presentation (slide 30) asserting that 62% of primary care providers in CT currently have provider risk/shared savings/total cost of care arrangements with providers. Questions relate to whether the populations included are representative of the state, provider types included, whether the number relies on one payer disproportionately, and the possibility of double counting among other issues.

Unfortunately this questionable number is being used as the foundation of a proposal that may undermine even the minimal quality standards in the current SIM proposal. Last week, in a private email, SIM steering committee members were asked for input on whether, given the perceived prevalence of provider risk, SIM should propose allowing provider incentives even in the absence of medical home status. Presumably this is to avoid jeopardizing the primary SIM goal of moving at least 80% of state residents into provider risk arrangements, regardless of quality protections. Advocates have called on SIM leaders to build a robust quality monitoring system before any provider incentives are implemented. Advocates are hoping to both improve the quality of care in CT and prevent the harm to people that occurred in managed care risk arrangements in the past.

The current SIM medical home plan is to create a CT-specific, lower standard than the commonly-used, well-vetted national accrediting bodies. (They have taken “person/patient-centered” out of the label for their lower standard.) There are currently 821 NCQA certified PCMHs in CT and the list grows every month. One third of Medicaid consumers are now cared for in a PCMH. It is important to note that a large proportion of Medicaid providers, with lower payment levels, have earned PCMH designation.