Delivery of Care

The SIM ship sets sail

After four years and $20 million, the SIM health care reform effort in Rhode Island seeks to create a new lifeline for sustainability

Image courtesy of the Rhode Island Department of Health

Slide from the presentation on Health Equity Zones at the SIM Steering Committee meeting on Jan. 10

By Richard Asinof
Posted 1/14/19
After four years and $20 million in federal grants, the Rhode Island SIM project is transitioning to try and sustain its efforts when the money runs out as of June 30, 2019.
When will The Providence Journal report on the innovative work on health equity zones and neighborhood health stations? In braiding together resources, does there need to be more focus on those without health insurance and those who are under-insured? In putting together the state health planning document, will there be an evaluation of how many hospital beds are needed in the future? How does public health become part of the health care delivery continuum? How do the diseases of despair – deaths from alcohol, suicide and drugs, tied to economic disruption, become part of the dataset?
There are five or six segments of the health care market: those covered with commercial health insurance plans through work, those covered through Medicaid, those covered with self-insured health plans through work, those covered through Medicare, and those who are uninsured or under-insured. Each of those segments experiences a different set of outcomes, based on: the cost of health care delivery, access to primary care, the cost of drug prescriptions, and the nature of chronic diseases.
Designing data strategies around advanced care directives, for instance, requires thinking through how the unmet needs for each segment can be met, given the different access – or lack of access – to care.

PROVIDENCE – Four years and $20 million later, the history of the State Innovation Model project is still being written about its efforts to transform health care in Rhode Island and create greater alignment around data, policies and population health, focused on documenting its accomplishments.

Much of the work took place behind the scenes of health care delivery, without much scrutiny by the news media or with direct interaction with patients.

Translated, SIM was a policy wonk’s dream, seeking ways to better implement health care reform in Rhode Island. Its history reflects the changing exigencies around health care reform, both here in Rhode Island and in Washington, D.C., as well as the rapidly changing landscape in health care during the past four years.

The initial effort to secure the SIM grant was coordinated by then Lt. Gov. Elizabeth Roberts, under a process known as the State Health Innovation Plan, or SHIP, with the process coordinated by the health care consultant, The Advisory Board, under an initial $1.6 million federal grant.

At the time, there were strong, behind-the-scene disagreements about what should be the focus of the SHIP report. The concept of neighborhood health stations, such as the ones operating in Central Falls and in Scituate, was excluded.

The final SHIP report, presented on Nov. 20, 2013, found that innovations proposed under the Rhode Island plan would lower – but not eliminate – the annual increase in rising health care costs by about 3 percent in the next few years.

As reported by ConvergenceRI: Instead of a projected 6-7 percent annual increase, health care costs would be held to about 4 percent a year in Rhode Island, according to the consultants. The findings, the consultants stressed, “were intentionally conservative.” [See link below to ConvergenceRI story, “Crunching numbers on the state health innovation plan.”]

[As it turned out, the initial consultant’s report matched the current SIM cost growth target for health care costs, tied to the potential gross state product, set at 3.2 percent for four years through 2022.]

Theory and practice
In 2014, Rhode Island was awarded a $20 million grant from CMS.

The theory behind the effort, as articulated in the Rhode Island SIM Theory of Change, goes as follows: “Rhode Island’s payment system is changing to focus more on value and less on volume. If SIM makes investments to support providers and empower patients to adapt to these changes, and we address the social and environmental determinants of health, then will we improve our population health and move toward our vision of the Triple Aim.”

Technically, the federal funding will cease as of June 2019, the end of the grant cycle, but there are ongoing conversations with the Centers for Medicare and Medicaid Services to find paths to create additional resources to sustain the project.

If nothing else, the effort has aligned many of the players involved with health care reform in Rhode Island, seeking to create synergies around integrated strategies.

Further, there is a renewed push to create a statewide health planning document, funded in part by The Rhode Island Foundation.

Health equity zones as part of the strategy
At the most recent meeting of the SIM Steering Committee on Thursday, Jan. 10, Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, presented a detailed presentation of slides documenting the work of nine health equity zones in Rhode Island, which have been included as key component of the SIM Transformational Wheel under “Patient Engagement.”

The goals include: improve health of communities with high rates of illness, injury, chronic disease, or other adverse health outcomes; improve birth outcomes; reduce health disparities; and improve the socio-economic and environmental conditions of neighborhoods.

Where do neighborhood health centers fit in?
Following Alexander-Scott’s presentation, a question was raised by one of the observers attending the meeting about how neighborhood health centers in Central Falls and Scituate fit into the SIM model around health equity and patient engagement. Stay tuned.


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