SIM update: PCMH standards affirmed but rushing into a radical Medicaid payment change

The good news: At yesterday’s meeting the SIM steering committee voted to accept their workgroup’s recommendation to use NCQA national standards, with some CT-specific additions, as the patient-centered medical home (PCMH) standard for the SIM glide path program. SIM will work with NCQA to develop the additional standards, possibly to include oral and behavioral health integration and cultural/linguistic standards. New practices, without any PCMH certification, will be offered support to achieve the new NCQA Plus standards. Existing PCMHs will not be affected by the decision.

The troubling news: To get the federal grant, SIM leaders believe they need to be more aggressive in Medicaid payment reform and have proposed a shared savings model to cover over 200,000 members starting Jan. 1, 2016. There are very few details on the proposal and committee members had a lot of questions. Consumer advocates raised significant concerns both in public comments and during the meeting. Concerns focused on an 1115 waiver with a global cap on federal reimbursements, HSAs for Medicaid members, reductions in current fees to providers but potential future savings payments, the lack of time and vetting through councils and committees for the proposal, and undertreatment/incentives to deny necessary care. Doubts have also been raised about SIM’s assertion that they must include radical Medicaid payment reforms to secure a successful SIM grant. Advocates noted that earlier successful SIM states’ Medicaid reforms followed a natural progression of ongoing reforms in those more mature states. And we’ve known about their plans for over a year. CT has a poor history with similar Medicaid incentives. Since CT Medicaid moved away from capitation in HUSKY to one focused on PCMHs, health outcomes are better, provider participation is up, and per person health costs are down.