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The SIM steering committee reviewed final recommendations from their work groups yesterday. The SIM project is developing payment and care delivery models for at least 80% of state residents – 3 million people or more and $30 billion in CT health spending. The recommendations are very detailed and specific, but they maintain that there is still an opportunity for revision. Advocates are concerned that the decision-making groups lacked consumer input, and that the process was largely conducted out of public view over a short few months in the summer. The state intends to apply for up to $60m in federal funding to implement the plan.  Most troubling, the plan includes moving 80% of state residents into a total-cost-of-care payment model within 5 years. Total-cost-of-care gives providers “responsibility for the value of patient care by tying a portion of payment to achievement of total cost and quality metrics.” It could include “gain sharing, full risk sharing, and/or capitation.” Proponents acknowledge that CT does not now have the monitoring infrastructure to ensure that savings are not achieved by denying appropriate care. Advocates are urging the state for a plan modification that requires a meaningful quality monitoring system be in place before any provider risk dollars attach. It is also critical that any incentive payments (or capitation withholds) be contingent on meeting meaningful, not minimal, quality standards. CT is well behind other states in capacity to measure quality and in performance.  SIM leaders do intend to create a metrics workgroup to develop quality standards. Hopefully this is a more diverse, transparent committee with all stakeholders represented.