State Innovation Model (SIM) Evaluation Report on Award Year 2 (AY2) Activities

Bentler, S.E.; Heeren, T.; Spinarski, R.Schultz; Momany, E.T.; Damiano, P.C.
05/2018

Abstract

This report covers the process and implementation activities of the State Innovation Model (SIM) test grant in Iowa during the last quarter of the first implementation year (November-December 2016 and January 2017), the three-month no-cost extension period (February – April 2017) and into the first two quarters of the second implementation year (May – October 2017).  The objective of the process and implementation evaluation is to describe the structure of the interventions and actions being utilized in the SIM initiative, along with identifying advances and challenges encountered during implementation. 

A variety of methods were used to gather the information provided in this report. The University of Iowa Public Policy Center (PPC) team reviewed documents and collected information from pertinent websites, participated in bi-weekly phone conferences with the state SIM team and the Center for Medicare and Medicaid Innovation (CMMI), participated in monthly phone conferences with the state SIM team and the national evaluators, conducted stakeholder interviews to understand how the SIM initiative was being implemented during this time period, and surveyed Iowans across the state to provide a population profile.

The end of SIM award year 2 and into the beginning of award year 3 was a period of change, planning to implement the changes, and progress toward goals. As in the previous year, a significant amount of time was spent working to facilitate collaborations with the multitudes of stakeholders integral to the successful implementation of the SIM activities. 

A summary of some of the successes and challenges in the implementation of the SIM activities in this reporting period are below.

Successes

  • All six Community and Clinical Care (C3) sites applied for and received year two SIM funding to continue their activities. In addition, a new C3 site with a healthcare system as the primary grantee was funded. The C3 sites continue to be the innovation laboratories for how to establish successful partnerships, provide care coordination, and improve the health of individuals at the community level. Communication between the SIM staff and the C3 organizations has improved. 
  • There has been a concerted effort to incorporate the collection, analysis, and reporting of data into almost all SIM activities. These efforts could allow for greater opportunities to track success and failure and provide important feedback to healthcare stakeholders to improve organizational processes. Activities included: 
    • reigniting the statewide alert network (SWAN), 
    • developing and using the SIM data portal, 
    • developing a community scorecard for the C3 communities, and 
    • supporting the value index score (VIS) dashboard for the payer and provider community. 
  • Initially, the SIM plan included many activities that were passively encouraged to be utilized by stakeholders to bring about delivery system change and payment reform. There has been significant progress in incorporating stronger policy levers into SIM initiatives to bring about change. Some of those levers included:
    • Requiring the use of SIM tools such as the statewide strategic plans (SSPs), the SWAN, data reporting, and technical assistance (TA) as part of the funding for the C3 communities.
    • Promoting state certification of the Diabetes Self-Management Education (DSME) programs as a way to encourage their widespread use. State certified DSME programs are reimbursed by Medicaid and some private insurers.
    • Introducing the idea of value-based purchasing (VBP) at the community level by incorporating the use of performance-based incentives and disincentives into the C3 required actions.

Challenges

  • Changes in key state leadership positions reduced the ability to implement some aspects of the SIM. Governor Terry Branstad resigned and was replaced by Lieutenant Governor Kim Reynolds. Charles Palmer retired as Director of the Iowa Department of Human Services (DHS) and Jerry Foxhoven became the new DHS Director. And Mikki Stier, the Iowa Medicaid Director, was promoted to Assistant DHS Director and a search began for a new Medicaid Director. The Award Year 3 Operational Plan for the Iowa SIM included plans to form a Healthcare Innovation and Visioning Roundtable; convening of the Roundtable was delayed due to these transitions in leadership.
  • Uncertainty in MCO contracts affected the MCOs ability to focus on SIM activities in award year 2 (AY2) and plan ahead for the metrics that they will be expected to reach in the coming years. There were some challenges advancing the SIM strategies for VBP while the state contracts with the Medicaid MCOs were under negotiation. 
  • There were challenges getting all hospitals (especially rural hospitals) connected to the SWAN and getting the larger healthcare systems to buy-in to its potential to improve care processes.
  • Keeping statewide interest in the SIM project is a challenge. Statewide Learning Event attendance significantly declined from the November 2016 (310 attendees) to July 2017 events (110 attendees).

Future considerations

  • With about two years left of the SIM, efforts will need to shift toward developing strategies to sustain the most successful SIM initiatives into the post-SIM period. These efforts may include identifying new partnerships, leveraging existing programming, and finding new funding sources to sustain successful initiatives.
  • A challenge for the coming year will be to re-establish state level leadership, visioning, and strategic planning for the SIM. Without leadership at the highest levels buying into the vision and direction of transformation efforts and helping to plan for the future beyond SIM, it may be difficult to sustain any momentum toward system change gained from the SIM activities. 
  • The SIM team has primarily worked with the Medicaid MCOs during award year (AY3) regarding VBP. Effort will need to be made to re-engage the Medicaid ACO providers in VBP discussions and activities.
  • Provider awareness of and active participation in delivery system and payment reform initiatives will be increasingly important in the coming years of the SIM to be able to institute reform statewide and keep efforts progressing post-SIM.