As I wrote in the recent UHCAN Ohio newsletter, Ohio received notice, in December, of a $75 million State Innovation Models (SIM) Test grant

The grant is to test new ways of paying for health care that “improve health system performance, increase quality of care, and decrease costs for [all private and public payers] and for all [Ohioans].” In other words, better health care that makes us healthier, at lower costs. But can they deliver on the promises? Or, will the conflicting interests of insurance companies, hospitals, and other stakeholders overshadow the needs of patients/Ohioans? And, is there anything Ohio consumers can do to increase the likelihood that SIM will improve the lives of all Ohioans – especially those who need improvements the most? Here’s the first in a series on the SIM Grant and how to protect consumers’ interests in Ohio’s changing health care landscape.  

What Will the SIM Test Grant Do?

 Here’s the summary from the CMS website:

Ohio will transform the state’s health care system by rapidly scaling the use of patient-centered medical homes (PCMHs) and episode-based models and by developing cross-cutting infrastructure to support implementation and sustain operations. By the end of the Model Test, Ohio plans to launch 50 episodes of care and implement PCMHs statewide. Reports for the first six episodes of care will be delivered to providers in November 2014. PCMHs will expand geographically, reaching statewide coverage by 2018. In addition, the state is focused on incorporating population health measures into regulatory and payment systems in order to use those measures to align population health priorities across clinical services, public health programs, and community-based initiatives.

Research shows that the PCMH model of enhanced primary care can improve patients’ care and their health, while lowering costs. The research also shows lots of variability in results, largely because the PCMH models tested are all different. And no research I’ve seen shows what elements of PCMH produce better results than others. In other words, the ability of Ohio’s spreading PCMHs to improve health outcomes and lower costs, probably depends on the specific features of each PCMH.

The other thing we know about improving our health is that the best doctors in the world can’t save you if you chain-smoke, don’t eat vegetables, breathe bad air, and have too many stresses in your life. In other words, improving the health of Ohioans involves medical care and our lives – where we live, work, and play.

What Can We Do to Improve the Value of the SIM Grant to Consumers?

Probably several things, if we organize. Consumer advocates can identify specific strategies (such as use of community health workers) that improve outcomes and/or save money and push for those elements to be included in Ohio’s PCMH model. Effective strategies include making sure that the PCMH practice (the office or clinic) include:

• Has people working there who are from the same communities, race, or ethnicity as the patients served there (a national best practice for reducing health disparities);
• Has the ability to connect patients to resources in the community than can help them improve their health; and,
• Has community health workers to help patients understand how to take care of their health and overcome non-health barriers in their lives.

A PCMH without these elements may work reasonably well for a patient population that is well educated, affluent, and in reasonably good health. For the rest of Ohioans, no way. Let me know if you have thoughts on this or want to help UHCAN Ohio and Ohio Consumers for Health Coverage make Ohio health transformation work for Ohioans.  

In future blogs, we’ll look at: How do we make sure consumers have a powerful voice in Ohio’s SIM Grant?  What are other states with SIM Testing Grants doing to make sure that health care system transformation improves lives?