5 ways payers factor into state innovation model report

A compass pointing to the word "Innovative"

Photo credit: Getty/Olivier Le Moal

In the second year of the government-backed state innovation model (SIM), the six participating states delved deeper in their mission to test various healthcare reform models--with payers, in some cases, playing a major role.

An analysis released this week chronicles the states’ various programs aimed at driving care coordination, population health management and payment reform. Several states, it noted, have expanded SIM-supported models’ patient populations.


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Here’s a closer look at how both government and private payers have been involved in those efforts, as well as some of the challenges that have arisen:

  • Maine, hoping value-based insurance design (VBID) holds the key to controlling healthcare costs, has convened a VBID work group charged with identifying best practices throughout the country, creating a way to rank insurance plans according to certain VBID metrics, and encouraging Maine businesses to adopt the new benefit model. “Ideally, this is not just a commercial payer effort--it’s across the board,” one leader said, according to the analysis.
  • Oregon has struggled with winning the support of commercial payers for its Patient Centered Primary Care Home Program initiative, a hurdle that some stakeholders worry could ultimately stifle progress. Private payers, though, are concerned that a PCPCH payment could “preclude them from trying out payment systems and models of care delivery that may be better suited to the individuals they insure,” the analysis notes.
  • Vermont formed a population health work group that includes providers, insurers, consumer and advocacy groups, universities, and state agencies. However, it has faced hurdles given the stakeholders’ often-competing interests, divisions over the definitions of population health, and time and labor restraints.
  • In three states--Massachusetts, Minnesota and Maine--Medicaid was the only participating payer in round 1 SIM initiatives. In the other three states Medicaid is one of several participating payers.  
  • No test state in round 1 implemented delivery system or payment reform models for Medicare, but both Arkansas and Oregon have included provisions for reaching Medicare-Medicaid enrollees through their SIM initiatives.