Medicaid, SIM committee update – PCMH success continues, SIM making important Medicaid decisions

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The Care Coordination committee of MAPOC has been given responsibility for oversight and advice on SIM’s controversial new plans for Medicaid, especially the shared savings payment model. The committee’s original mission remains as well – to track Medicaid’s successful patient-centered medical home program.

In yesterday’s meeting we heard more about continuing PCMH success. The number of participating practices is accelerating every quarter. Even as enrollment climbs with the ACA expansion, the percent of members served by a PCMH remains at 32%, matching growing capacity with growing demand. Unfortunately since the last report, a large hospital-affiliated practice decided not to renew PCMH certification citing financial reasons. It was reported that some payers increasingly prefer to reward large practices with advanced analytic and other capacities that support shared savings (as well as quality in some cases) at the expense of PCMH supports (which focus on quality and access to care, but do save as well).
The SIM update reiterated the intent, over advocates’ objections, to have the underservice and quality measures developed by SIM’s Equity & Access and Quality Committees apply to Medicaid. To improve chances of getting the federal SIM grant, the Quality Committee adopted Medicare ACO quality measures as the basis for the entire state population. Advocates have argued that Medicaid serves a very different population with different needs than Medicare or commercially insured populations. Advocates are concerned that the SIM committees are dominated by commercial insurers, who no longer have a role in the state’s Medicaid program, and little Medicaid consumer representation. We were told that the PCMH SIM committee, that includes Medicaid expertise, can review the SIM committees’ decisions, but cannot use a more appropriate set of standards.