Friday, December 20, 2013

SIM update

SIM leaders released their financial analysis, response to public comments, and revised vision statement at the last meeting. We will be providing a longer analysis when the final plan is available, but a few points bear highlighting. Despite strong public comments voicing concern about under-treatment incentives in shared savings, SIM leaders recommended not to include a commitment to monitor for under-treatment and deny savings payments generated by under-service. They argued that all seven insurers have not agreed to it, and they can’t make them do anything. Members of the steering committee argued that the entire document is aspirational and unenforceable, and that it was a clear message from public commenters. In response, the group agreed to add language to the vision statement. They also included language about engaging stakeholders, another common complaint in public comments.

They intend to pursue plans to develop a CT-specific patient-centered medical home certification, bypassing the current, widely accepted national NCQA standards. (There are currently 891 NCQA PCMHs in CT; that number grows every month.)

They have carved out long term care, DMHAS clients and (to some extent, see below) Medicaid consumers from the SIM for a variety of reasons.

They will not be reinstating the payment reform workgroup. They will continue to set policy with payers in private, non-public meetings.

The financial analysis expects that Medicaid providers will receive only 30% of the savings they generate (including care management payments), compared to 45% for providers caring for commercially insured consumers. This is on top of lower Medicaid fee-for-service rates. At a subsequent Cabinet meeting, SIM leaders stated that these numbers were only for illustration and promised to get back to us with the source of the inequity. They have based return on investment calculations on the questionable assertion that 40 to 60% of CT primary care providers are now in shared savings contracts. Several members expressed doubt about this assumption.

New language reportedly negotiated since the meetings includes some limits on shared savings models in Medicaid and a commitment to delay shared savings until under-service monitoring is in place — but only for Medicaid.

The final plan will be submitted to the Center for Medicare and Medicaid Innovation on Dec. 30th.