State Innovation Model – 75 Million Reasons to Pay Attention

By Mark Ridenour

In December, the Center for Medicare and Medicaid Innovation (CMMI) awarded a $75 Million four year grant to the Ohio via its State Innovation Model (SIM) awards to implement a payment reform model which will broadly move reimbursement models to recognize outcomes over volumes.  Providers will get increased reimbursement for providing more efficient care while maintaining or improving quality.  Ohio budget projections suggest another $125 Million in state funds could be added over the life of this project.  The stated SIM goal is to have 80-90 percent of Ohio’s population in some value-based payment model within five years.

The Ohio Office of Health Transformation (OHT) led by Director Greg Moody will manage this project.  There are two primary vehicles designed to work together to implement this change: 1) Episodes of Care and 2) Medical Homes.  (see chart below) The state will require each of the managed Medicaid insurers (CareSource, Buckeye, Molina, Paramount, and United) to participate along with the four largest commercial insurers (Anthem, Aetna, Medical Mutual and United).  In 2015, these payers will share data with providers on selected Episodes and begin to change payments in 2016.  The initial Episodes are Perinatal, Asthma acute exacerbation, COPD exacerbation, Percutaneous Coronary Intervention (PCI), and total joint replacement.


There are now over 500 accredited Medical Homes in Ohio.  This project will initially work with the 75 Medical Homes in the Cincinnati-Dayton region already engaged with the Comprehensive Primary Care initiative (CPCi), additionally funded by CMS.  This will progress by region in Ohio most likely taking advantage of the significant work already accomplished by the health collaboratives, Better Health Greater Cleveland and the Healthcare Collaborative of Greater Columbus.  The OOA has been a supportive participant over the past few years, although optometry has yet to demonstrate an impactful relationship.

Capture 1This chart represents the variability in total costs across an episode and how the OHT envisions introducing risk and gain sharing.  While the initial episodes chosen do not directly involve optometric care, we are confident that as the list grows to the expected 50 episodes they will likely include diabetes, glaucoma and/or cataract care.  The OOA has been engaged with the OHT so will be part of the stakeholder groups helping to shape this effort.

What can you do now to prepare for the changes brought about by this significant investment in the State Innovation Model (SIM)?  1) affiliate with Medical Homes and 2) maintain an Electronic Health Record (EHR) which meets Meaningful Use standards.

The best position for optometry as the primary eye care provider is to solidify our standing as part of primary care team via alignment with Medical Homes.  You should survey your primary care referral sources to see if they are an accredited Medical Home or are in process.  Maps and lists of accredited practices are available on the Ohio Department of Health website.  In addition, even though the promise of electronic interconnectedness has yet to be realized, participating in risk-sharing, outcomes-based reimbursement vehicles will be largely dependent on providers having EHRs with the ability to send and receive data.

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