PROVIDENCE – If you’re ready, fasten your seat belt, put on your health policy wonk helmet, and then, take a deep breath.

ConvergenceRI is about to dive into the swirling waters surrounding Rhode Island’s recent $20 million award to implement and test its State Innovation Model to transform health care delivery.

The mission impossible, one that ConvergenceRI has chosen to accept, is to translate the details of the revised project narrative and budget, submitted on Dec. 3, 2014, into an easy-to-understand story, making it conversation-ready.

In doing so, ConvergenceRI seeks to recognize SIM’s strengths as well as expose potential problems with the plan – things that may make the business of transforming health care delivery in Rhode Island more difficult to achieve.

The post-Copernican world in health care
Rhode Island has emerged as a national leader in health innovation – in part because of its size, its leadership at the community, state and institutional levels, and their willingness to embrace health care reform as an evolution moving toward patient-centric and patient-directed care, moving away from fee-for-service, hospital-as-hotel business models.

It is also related to the emerging innovation ecosystem in the biomedical industry and health IT sectors, the research engine that attracts $250 million a year to the state’s academic research centers, and numerous community-based initiatives that put the focus on creating healthier housing and healthier communities.

To date, health innovation has often been kept separate from discussions of Rhode Island’s future economic development plans, and its many facets remain un-mapped, un-coordinated, and in silos.

Rhode Island’s new SIM award seeks to impose its own ordering of the health innovation universe as a function of state government, in partnership with the state’s private health care delivery industry sectors, tied directly to state investments in delivery transformation and in health IT, with the goals of controlling costs and improving population health outcomes.

It segues with the recent compact developed under the leadership of Sen. Sheldon Whitehouse and Neil Steinberg, president and CEO of the Rhode Island Foundation, to create a unified statewide structure of stakeholders to advocate for health care reform and payment reform. [See link to ConvergenceRI article below.]

Yet it remains unclear how, in this new world of patient-directed and patient-centered care, the actual patient gets to participate and make his or her voice heard in the delivery of care – except as a customer, receiving care and paying the bills, however reluctantly.

The patient is left out of the governance structure of the SIM grant, which is given to a large group of institutional stakeholders, known as the Healthy Rhode Island Steering Committee. The only so-called “community” voices on the committee are The Rhode Island Foundation and the Greater Providence YMCA.

And, the limited resources committed – $20 million awarded instead of the $58 million sought – means that Model Test envisioned will be, by definition, limited.

The cost conundrum
The importance of the Rhode Island’s SIM award takes on added significance in the wake of Vermont Gov. Peter Shumlin’s decision to pull the plug on his state’s single payer plan because of its high cost.

It raises the ante on whether Rhode Island can demonstrate that it can control its rising medical costs by investments in health care delivery transformation, in shared-shavings Accountable Care Organization business models, and in health IT.

It’s a very good question to ask and test out; but, as with Vermont, the answers around achieving cost control may prove surprising.

The Rhode Island plot line may get further blurred by the fact that the former manager of Vermont’s $45 million SIM plan [as well as its principal author], Anya Rader Wallack, has been chosen by Gov.-elect Gina Raimondo to replace Christine Ferguson as the executive director of HealthSourceRI.

The seeming unity of the SIM grant narrative has obscured real, ongoing important policy disagreements about how the money should be spent and, perhaps more importantly, choices for alternative models for care delivery.

Many potential alternatives have been “excluded” from the conversation and the grant: community-based collaborative Neighborhood Health Stations; front-end investments in prevention, nutrition and wellness; healthy housing initiatives; and the sophisticated integration of health IT at the point of care by local community health centers, with shared savings flowing back to them and not the insurers.

The SIM project’s initial step is to conduct a comprehensive population health epidemiological survey, which may prove to be one of the most valuable parts of the entire project: detailing the facts around Rhode Island’s population health, community by community. It raises the question: how will the plans change based upon the fact-based evidence quantified by this effort?

For sure, there are some risks involved in ConvergenceRI’s voyage into the details of Rhode Island’s SIM grant: not everyone is pleased with what happens when someone turns over rocks and asks impertinent questions, making the budget decisions transparent.

The benefits, however, outweigh the risks: it’s important for Rhode Islanders to grasp the policy choices being proposed, in order to participate in the conversation as the process moves forward.

The promise of SIM
On its glittering surface, the $20 million award over four years from the federal Centers for Medicare and Medicaid Innovation, a division of the Centers for Medicare and Medicaid Services, offers Rhode Island a great chance to pursue health innovation from a population health perspective.

The articulated goals for the Test Model, as it is called, are coherent: “Rhode Island envisions a new system of care that supports lifelong health for the state’s populations.”

Six fundamental characteristics make up the state’s vision of value-based care:
• The first two are an orientation to outcomes and population health management, aligned with values that match the aspirations, needs and objectives of the community.

• A third promotes effective provider relationships, linking a team-based approach to primary care practices and population health management, connecting the practice of health care to the community as well as providers.

• A fourth is that the person seeking care is active and engaged in shared decision-making with the provider.

•A fifth promotes alternatives to fee-for-service payment models, such as shared savings and pay-for-performance models, such as Accountable Care Organizations. The goal is to have 80 percent of payments to providers from fee-for-service alternatives that link payment to value, something Rhode Island hospitals and insurers have already targeted as an achievable goal by 2019.

• The sixth is the effective use of health information technology as an effective tool supporting transformation.

So far, so good, as far as the choice of words to describe Rhode Island’s SIM overarching goals.

The population health goals, likewise, choose many of the right targets: obesity, diabetes, heart disease and stroke; smoking prevalence; cancer morbidity and mortality; preventable emergency department visits, hospitalizations, and readmissions; behavioral health morbidity and mortality; prevention of infectious disease; child health, including immunizations, developmental screening and referral, and asthma control; infant mortality (C-section rate and premature delivery); and end of life care and palliative care.

Where it all gets a bit dicey, however, is in the budget details and policy priorities.

Follow the money
For those that want to follow the path of Rhode Island’s SIM, it first began with SHIP, the Rhode Island State Health Innovation Plan, developed by a Washington, D.C.-based consultant, The Advisory Board Company, in 2013. It served as Rhode Island’s preliminary submission, based on the potential analytics of slowing the 7 percent growth rate in annual medical spending to 3-4 percent in three years’ time. [See links to ConvergenceRI stories below.]

In the next version of Rhode Island’s plan, now known as SIM, the state was asked to submit a plan that linked population health to health care delivery transformation. In July of 2014, the state submitted an application for about $58 million.

In November, CMS asked Rhode Island to resubmit their plan and budget for $20 million. At first, Rhode Island submitted a $23 million budget; the feds asked again for a $20 million budget, which was submitted on Dec. 3 and the grant was awarded two week later.

In essence, the award provides for about $5 million a year over the next four years.

Six new state jobs
Under SIM, the program will create six new state jobs, with the bulk of the money for personnel to be spent as follows:

• $1.96 million in salaries for six FTE high-level state employees, with $1.13 million in fringe benefits, for a total cost of about $3 million for personnel, or 15 percent of the award.

These positions include: a director of the overall SIM project at the R.I. Executive Office of Health and Human Services, at $96,283 a year for four years; a health information specialist, also at EOHHS, at $96,000 a year, for three and half years; a senior epidemiologist at the R.I Department of Health at $76,523 a year, for three and a half years; a systems data analyst at HealthSourceRI, at $122,038, for three years; a policy associate at R.I. Office of the Health Insurance Commissioner, at $96,283, for three and a half years; and a chief of transformation at R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, for $122,038, for three years.

In other words, about 15 percent of the grant will flow to create six new high-level jobs within the state’s existing bureaucratic structure to manage the implementation of the new program. It’s definitely a top-down approach.

In addition, the project director at EOHHS will have $200,000 over four years, or $800,000 in total to hire consultants to manage the workflow of the SIM program, including reporting requirements.

For the behavioral health transformation part of the project, $375,000 has been allocated over two years, or $750,000, for the chief of transformation at BHDDH to hire an expert consultant to develop its plan.

For the development of the population health plan, $375,000 has been allocated over two years, or $750,000, to hire an expert consultant to develop the population health plan.

Translated, the six new employees, with salaries and fringe benefits of $3 million, will have a total of $1.55 million in their budget to hire expert consultants to develop and manage their work plans.

That’s a total of $4.55 million – 23 percent of the grant – to pay for six new hires to manage the project and to develop, monitor and report on the work plans.

None of those jobs and none of those consulting contracts are necessarily guaranteed to go to Rhode Island residents or firms.

Investments in transformation
Rather than reinventing the wheel, so to speak, the SIM project seeks to build upon existing structures to transform Rhode Island’s health care delivery system – including the all-payer R.I. Chronic Care Sustainability Initiative, or CSI-RI, a patient-centered medical home model of care that has expanded to provide primary care to about one-third of Rhode Island’s population, even if the patients may be unaware that they are part of a PCMH.

The Rhode Island Foundation serves as the Initiative’s fiduciary parent, which recently officially changed its name to Care Transformation Collaborative of Rhode Island, or CTC.

Indeed, about $4.5 million of the SIM award’s financial resources – broken down into $1.14 million a year budgets over four years – are targeted for health care delivery “transformation” contractual investments. The bulk of those investments, some $3 million, appear to be dedicated to future Care Transformation Collaborative plans to move beyond its current adult primary care focus, with new programs for pediatric care, behavioral health, and community health teams to reach high-risk patients.

According to the budget narrative, the line items include:
• Practice Assistance, $650,000, a current CTC programmatic area, working with contractors such as Healthcentric Advisors.

• Community Health Teams, $1 million, a current CTC programmatic area.

• Patient Centered Medical Home expansion to pediatrics, $500,000, a planned expansion of the CTC programmatic area.

• Child Psychiatry Access Program, $750,000, a planned expansion of the CTC programmatic area.

Two contractual line items, one for Advanced Illness Care Initiative, at $420,000, and another for “Behavioral Health” transformation, budgeted at $1.25 million, which includes a public health approach to the delivery of early intervention and treatment services for people with substance abuse disorders, appear to be outside of the CTC programmatic area.

Bumps in the road
A few caveats about CTC and its model, formerly known as CSI-RI: the impetus has been on changing the culture of the way health care is delivered by the practices, by promoting a team, patient-centered medical home approach, and in doing so, changing the behaviors and outcomes of the patients, particularly those with chronic diseases, as a way to cut costs and improve population health.

There may be a few bumps in the road ahead. Its new program expansion known as CTC-Kids, focused on pediatric care, is slated to receive $500,000 under SIM. But the initial recruitment failed to attract many of Rhode Island's larger community health centers as participants, the ones that serve the largest number of children, because of problems connected with reimbursement.

CTC does not directly address Rhode Island’s population that is uninsured or under-insured, where affordability and access to care are major barriers to proper health care – as well as major drivers of cost. Having an insurance card does not translate directly into the ability to access care. [And, there are still about 50,000 Rhode Islanders who fall into the uninsured camp.] 

Health IT
Another $6.5 million of the SIM money is targeted for contractual work for health IT, the bulk of which appears to be dedicated for investment in the Rhode Island Quality Institute, a quasi-public created by Sen. Sheldon Whitehouse when he served as R.I. Attorney General. The Institute has been responsible for the development and implementation of Currentcare, the state’s health information exchange, with mediocre results to date.

Within the project narrative, these include targeted investments in the creation of a statewide common provider directory, budgeted at $1.5 million. The R.I. Quality Institute had already been tasked with developing such a provider directory as part of its existing contractual obligations, but it has not yet completed the task. The new money will be used to “leverage the federal investment to date” from the 2010 Beacon grant, according the project narrative.

While the idea behind the statewide common provider directory is to create a shared database, the underlying intent, as stated in the project narrative may prove a bit troubling: to create statewide control of relationships between individual providers and provider organizations, to play a critical role “when calculating quality, utilization and cost measures upon which the provider and provider organizations will be paid.”

In other words, the intention appears to be to create a built-in dependency on the R.I. Quality Institute, in effect requiring a toll bridge on the quality reporting road as part of the health information superhighway. Given the R.I. Quality Institute’s struggles with interoperability around Currentcare, the quality reporting database could instead become a significant roadblock to the sophisticated use of health IT at the point of care.

As some critics maintain, providers should be able to manage the data of their own patients at the point of care, in order to provide the best possible care and to bend the cost curve by conducting their own analytics – and not become dependent on a slower, more inefficient statewide system.

Currentcare has encountered many difficulties: only about two-fifths of the state’s residents have enrolled to date, despite financial incentives paid to physicians to enroll their patients. In addition, there have been difficulties around interoperability and the up-to-date currency of the actual records being stored by Currentcare. There is also the problem of signing in: a physician or nurse practitioner has to leave their own EMR site, and sign on to Currentcare, a clumsy interface.

To help remedy some of these glitches, the SIM grant provides $1 million in its budget to expand the patient engagement tools of Currentcare – replicating what many patient engagement apps in the marketplace already allow consumers to do, such as self-report data into one’s electronic health record. It remains to be seen whether Currentcare’s efforts to compete in the market against more nimble tools already in use will result in greater consumer participation in Currentcare. [The single sign-on project was apparently scrapped when the budget was cut.]

Quality metrics, All Payer Claims Database
The SIM grant also budgets $2.2 million for the development of a statewide system of quality measurement, reporting and feedback system, focusing on collecting providers’ clinical data at the individual or aggregate level, in order to calculate “a harmonized set of clinical reporting measures.” The work builds upon the current collaboration of the R.I. Quality Institute, Healthcentric Advisors, and CTC.

Further, the SIM grant commits about $2 million in additional funding for the All Payer Claims Database, more than four years in the making and still not completed. The grant money, according to the project narrative, is needed to ensure “continued operations and additional report generation in order to assure sufficient data collection and analysis related to value-based purchasing,” in order to sustain the database over time.

The question raised, or course, is whether the $2 million investment in the All Payer Claims Database will actually make it sustainable, or whether it will serve as a way to keep the project going. Its value as a tool in health care delivery is still unproven. It is not expected to debut until sometime in 2015.

Building the state’s data and analytics capacity
The final chunk of investment under the SIM grant is $3 million under the heading, “State Data and Analytics Capacity Planning and Development.”

As best as can be determined by the narrative, the investment seeks to build out the state’s capacity to conduct value-based analytics as part of the its management of its Medicaid program as well as the State Employees Health Plan. “This will require a thoughtful approach to data systems modernization and analytic capacity building,” the narrative reads, whatever that means. In actual practice, the state will spend the money to hire a contractor to develop a “data and analytics modernization plan” to be implemented over the course of the SIM grant.

In other words, it’s a $3 million investment in building out the state’s analytic infrastructure.

Governance of the grant
An ad hoc group, known as the Healthy Rhode Island Steering Committee, will serve as the governing body for the SIM grant.

From state government, it includes: the Governor and Lt. Governor, the directors of EOHHS, the Department of Health, BHDDH, OHIC, and the Department of Administration, including HealthSourceRI and the State Employee Health Plan.

From health insurers, it includes: Blue Cross & Blue Shield of Rhode Island, UnitedHealthcare of New England, Tufts Health Plan, and Neighborhood Health Plan of Rhode Island.

From hospital systems, it includes: Care New England, Lifespan, South County Hospital, and CharterCARE.

From physicians groups and practices, it includes: Coastal Medical, the R.I. Primary Care Physicians Corp., the R.I. Health Center Association, and the R.I. Medical Society.

From behavioral health, it includes: the R.I. Council of Community Mental Health Organizations, and the Drug and Alcohol Treatment Association of Rhode Island.

From children and youth, it includes: Rhode Island Kids Count.

From long-term care, it includes: Carelink.

From the community, it includes: YMCA of Greater Providence, and the Rhode Island Foundation.

Where’s the patients’ voice? Where’s the community voice? What? I can’t hear you.