State-based Health Care Transformation
State governments are uniquely positioned to use a wide array of policy levers, engage a broad range of stakeholders, and build on existing efforts to improve health care delivery and health outcomes.
Recognizing this potential, in 2013, the Center for Medicare and Medicaid Innovation (CMMI) awarded over $250 million to six test states—Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont—under the State Innovation Models (SIM) Round 1 Initiative. In 2015, CMMI awarded over $600 million to 11 new test states—Colorado, Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Ohio, Rhode Island, Tennessee, and Washington—under the SIM Round 2 Initiative. The primary objective was to test the ability of state governments to use their policy and regulatory levers to accelerate health care transformation efforts in their states.
Under both the SIM Rounds 1 and 2 Initiatives, states used a variety of strategies to encourage health care providers to adopt health care models that promote coordination across provider types, integration of primary care and behavioral health care, and address population health. Strategies included:
- Convening Stakeholders: States convened commercial payers and providers to discuss aspects of payment model design, such as quality measures used in payment models.
- Technical Assistance: States offered technical assistance to primary care practices and other providers to implement new delivery system models and enhanced services—such as health information technology (health IT) and data analytic investment—to enable or improve model effectiveness.
- New Payment Models: States changed payment models used by Medicaid and, where possible, aligned those payment models with new or existing efforts across Medicare and commercial payers.
- Regional Entities: Some states established or further developed regional organizations or coalitions to integrate with health care providers and address care coordination or health-related social needs.
Using Innovative Mixed Methods to Analyze Impacts on Health and Health Care
CMMI contracted with a team led by RTI experts to conduct independent evaluations of the SIM Rounds 1 and 2 Initiatives. The evaluations sought to understand how states implemented delivery and payment reform activities and to rigorously analyze the impacts of these activities. The analyses included:
- Qualitative Research: RTI conducted qualitative research through interviews with state officials, payers, and providers and focus groups of providers and consumers involved in new delivery and payment models. This qualitative data was used to document and analyze the perceived successes and challenges of the states’ implementation activities.
- Quantitative Analyses: RTI also conducted claims-based quantitative analyses to detect significant changes, if any, in health care and outcomes in the three years following implementation of the SIM Initiative.
RTI synthesized results from these qualitative and quantitative analyses to provide a comprehensive understanding of the SIM Initiative over time.
Framework for Understanding Implementation and Impact of the SIM Initiative
Our team developed a framework for understanding how the SIM Initiative could affect key outcomes of health and health care.
Impacts on Quality, Utilization, and Spending Outcomes
States differed greatly in their approaches, but there were generally favorable impacts associated with SIM-supported models:
- Patient-centered medical home (PCMH) models: PCMH models were associated with greater use of physician visits (Arkansas, Massachusetts, and Oregon) and having an annual primary care visit (Connecticut, Delaware, and Rhode Island) relative to their comparison groups, as would be expected from models that emphasize greater access to outpatient care. PCMH models were also associated with relative decreases in total spending (Delaware, Connecticut, Idaho, New York, and Ohio) and emergency department visits (Delaware, Connecticut, Ohio) relative to comparison groups.
- Episodes of Care (EOC) models: Two EOC models analyzed in Arkansas (perinatal and upper respiratory infection) demonstrated significant improvements in quality across multiple outcomes. Improvements in quality measures were more limited among episodes of care models evaluated in Tennessee and Ohio.
- Accountable Care Organization (ACO) models: Medicaid ACO models (Maine, Vermont, and Minnesota) and a state employee ACO model (Washington) reduced the rate of emergency department visits for patients relative to comparison groups.
- Behavioral Health Integration (BHI) models: BHI models were associated with relative decreases in emergency department visits (Colorado and Washington) and relative increases in behavioral health visits (Tennessee and Washington) relative to comparison groups.
Informing Policy and Lessons for Policy Makers
As CMMI’s evaluator for the SIM Initiative, RTI offers evidence-based lessons on leveraging policy and partnerships to accomplish key health care goals:
- Convening stakeholders and testing new models of care delivery can inform future policy. SIM-supported activities led to passage of new state legislation to shape future health care transformation.
- States can increase provider participation in value-based care through purchasing power under Medicaid and state-employee health plans, and by convening commercial payers toward aligning on value-based payment priorities.
- Alignment across multiple payers can enhance Medicaid and Medicare model impacts and help facilitate the transition to value-based care.
- Medicaid agencies can adopt payment models—together with other supports like technical assistance—to develop providers’ ability to manage cost and quality.
- Population health initiatives—such as community health workers, screening and referral systems, and data analytic or coordination tools—can help identify patients’ needs, connect patients to resources, and fill gaps in their care.
- Flexible funding, like the SIM Initiative, allows states to implement novel strategies tailored to their ongoing efforts and needs. These strategies may be time- and resource-intensive, but can provide significant contributions to patient-centered care, care coordination or integration, and population health by building on existing strengths.
The experience of the SIM Initiative states has relevance for other ongoing and future health system reform efforts. Policy makers can look to lessons learned from how SIM states leverage policies and strategies intended to grow delivery system and payment models to reach more providers and consumers. The evaluation results may guide decisions to help build the infrastructure and capacity to operate delivery system and payment models and help refine strategies based on stakeholder feedback and recognition of a changing environment.
