State Innovation Models Initiative:
Medicaid Delivery System Innovation
& Payment Redesign
Jim Roberts, Policy Analyst
NW Portland Area Indian Health Board
Quarterly Board Meeting
Thunder Valley Casino Resort
July 7, 2015
Objectives of the
Affordable Care Act:
Insurance
Market
Reforms
Increase Access, Improve
Quality, & Lower costs
Workforce
Development
Expand
Medicaid
Coverage
State &
Federal
Insurance
Exchanges
Center for Medicare &
Medicaid Innovation
ACCESS, QUALITY, AND COST:
• Affordable Care Act (ACA) established the
Center for Medicare & Medicaid Innovation
Center
1. Test new innovative payment and service delivery
models to reduce program expenditures
2. New models must preserve or enhance the quality
of care provided to Medicare, Medicaid and the
Children’s Health Insurance Program (CHIP)
beneficiaries
• Eliminate waste, fraud, and abuse
CMMI Payment & Service
Model Categories
Defined in the ACA Section 1115A
1.
2.
3.
4.
5.
6.
7.
Accountable Care
Bundled Payments for Care Improvement
Primary Care Transformation
Medicaid & CHIP Initiatives
Initiatives focused on Medicare & Medicaid enrollees
Initiatives to Speed Adoption of Best Practices
Initiatives to Accelerate the Development and Testing
of New Payment and Service Delivery Model
State Innovation Model (SIMs)
Grants to States & Facilities
• CMMI has provided over $1.3 billion in grants to
States and Facilities (providers) to test payment and
service delivery models
o Round One: $640 million to 25 States
o Round Two: $1 billion to 28 States, 3 Territories, & the District
• States are eligible & received:
o
o
o
o
o
Model Pre-Testing Awards
Model Test Awards Round 1
Model Test Awards Round 2
Model Design Awards Round 1
Model Design Awards Round 2
What are the SIMs Grants?
Model Pre-testing
• Three states received pre-testing assistance
and funding to work on a comprehensive
State Health Care Innovation Plan.
• States that received pre-testing awards
under the State Innovation Models initiative
had six months to submit their State Health
Care Innovation Plans to CMS.
What are the SIMs Grants?
Model Test Awards – Round 1
• Over $250 million in Model Test awards is supporting
six states to implement their State Health Care
Innovation Plans.
o Oregon received $45 million
• A State Health Care Innovation Plan is a proposal
that describes a state’s strategy to use all of the
levers available to it to transform its health care
delivery system through multi-payer payment reform
and other state-led initiatives
What are the SIMs Grants?
Model Test Awards – Round 2
• Round Two SIM Initiative Model Test awards
issued on December 16, 2014.
• 38 total SIM awardees (including 34 states,
three territories and DC)
o Idaho $40 million
o Washington $65 million
• States will work to develop state-based
innovation in health system transformation.
What are the SIMs Grants?
Model Design Awards – Round 1
• Sixteen states received Model Design
awards under the first round of the SIMs
Initiative.
o Idaho received $3 million
• States will develop and use Health Care
Innovation Plans to inform their applications
for a Model Test Award or another Model
Design Award under the second round of
this initiative
What are the SIMs Grants?
Model Design Awards – Round 2
• The SIMs Initiative Model Design Awards will
provide financial and technical support to
awardees for their planning and design
efforts.
• 18 States received $39.5 million
• In planning and designing their proposals,
states must:
o develop multi-payer payment and service
delivery models
o engage a broad range of stakeholders.
Why is this important for Tribes?
•
State proposals will change Medicaid delivery systems and redesign
payments; migration from FFS to volume and value-based
purchasing
•
State Health Care Innovation Plans (ID, OR and WA) had very little if
any Tribal input or consultation
•
Past experience in Medicaid system (managed care) and payment
reform has been very disruptive for the Indian health system
•
Key Indian states are in the wake of reform: (ID, OR, WA, MN)
generally centered in Medicaid Expansion States
•
Likely little impact on Encounter Rate but bundled services, valuebased purchasing, and incentive payments will impact availability of
services that can be billed.
•
Delivery System Reform Incentive Payments (DSRIP) will increasingly
become more important for the I/T/U
•
Medicaid Managed Care will continue to become more rigid and
network will become tighter
Delivery System Reform
Incentive Payment (DSRIP)
• Provides States with savings to support hospitals and
providers and how they change providing care to
Medicaid enrollees
• DSRIP payments are performance based incentives
• Medicaid Providers MUST meet certain milestones or
performance metrics
o Metrics are common across ALL providers and measured at early
years of the Waiver
o Metrics include both infrastructure development or system
redesign and focus on health outcomes in later years
o Infrastructure Example: implementation of chronic care registries
o System Redesign Example: Medical homes or integration of
physical and behavioral health
o Outcome Measures: clinical indicators to improve health of
population
Where do we go from here?
• Healthier Washington Initiative and Global Waiver:
o Tribal Technical Workgroup
o NPAIHB/AIHC Letter and White Paper recommendations
(handouts)
o Series of meetings over next two months
• Oregon 1115 CCO Waiver Renewal is pending
o NPAIHB Meeting with OHA on 6/24th; develop a Tribal Chapter in
the Waiver
o Need to schedule meeting with Oregon THDs
• Idaho Health Care Innovation Plan and SIM Grant
o Pending discussion about engaging Tribes
o Teleconference or webinar with State
o Arrange Workgroup follow up meetings at Idaho State/Tribes
Meetings
NPAIHB/NIHB Contract to evaluate CMMI &
State Implementation of SIM Process
• $50,000 Proposal submitted to NPAIHB to evaluate CMMI and
State implementation to include Tribes in State Innovation
Model work.
• Case Study approach: Minnesota and Washington
• Follows Case study methodology that NIHB used in 1997 to
develop Medicaid Managed Care Study.
• Develop advisory committee in each state to guide
development of case study reports
• Identify common themes, issues and then develop
recommendations for each state as well as nationally
• Will include recommendations for CMMI
• Convene national venue to discuss findings, refine report
recommendations and then submit to CMS/CMMI
Questions?