Payer support and SIM

In Colorado, public and private payers have voluntarily developed a multi-payer approach to support and expand broad-based accountable, whole person, patient-centered care transformation through a variety of initiatives. Within this landscape, seven payers signed a Memorandum of Understanding (MOU) with the SIM office, in which they committed to work collaboratively with SIM to transform the way primary care and behavioral healthcare are delivered and financially supported in the practice sites selected for SIM within these networks. These payers are collaborating to:

1. Focus on primary care practice sites and behavioral health settings seeking to ingrate care
2. Support providers in delivering and coordinating integrated care that improves population health, and increases quality while reducing costs
3. Increase providers’ abilities to manage whole-person care
4. Develop necessary infrastructure to support integration and delivery of whole-person care
5. Encourage practice sites to continually evolve towards higher-levels of integration through transformation of care delivery support by alternative payment models (APMs)

Payers participating in SIM have agreed to apply organization-specific payment model(s) and establish their own agreements with practice sites selected for SIM. Payers already have APMs in place with many practice sites in their networks to support primary care transformation. For SIM, value-based payments received through a payer-specific APM will support practice site work around behavioral health integration.

Payers’ existing APMs are already tied to outcomes measures for each plan, and payers are working collaboratively to align their measures in support of behavioral health integration. Participating payers have aligned practice expectations to the SIM Practice Transformation Building Blocks. Payers’ payment methodologies are designed to support practice capacity and infrastructure to achieve the milestones within these building blocks during the course of the initiative. Additionally, payers have aligned around the SIM set of CQMs and claims-based measures that will help practice sites identify things that influence healthcare quality, utilization, and costs.

While each payer is using its own payment model to support SIM’s transformation goals, the payment model(s) that payers will apply to SIM participating practice sites include the following basic elements:

1. Fee-for-service payments
2. Payments that include behavioral health integration through one of the following mechanisms:
   1. Upfront payments
   2. Population-based payments (e.g., PMPM)
   3. Care coordination payments
   4. Payment for additional codes
3. Shared savings opportunities OR incentive payments based on performance and/or outcomes linked to quality

Selection for SIM practice transformation support DOES NOT guarantee that practice sites already receiving payment support from payers will receive any additional value-based payments for participation in SIM. As noted, payers are establishing their own agreements with practice sites and using different approaches that include:

1. Continuation of existing models/commitments: Some payers are continuing existing payment arrangements with practice sites that are already participating in APMs; this includes practice sites participating in other payer-specific or federal initiatives.
2. Extension of existing models/commitments to new practice sites: Some payers are extending the models used in current initiatives (e.g., CPC+, payer-specific programs/projects) to additional new practice sites participating in SIM.
3. Modification of existing models/commitments to include new funding: Some payers have modified the models used in current, ongoing initiatives to include new funding for progression through the practice transformation milestones outlined in the Colorado SIM Framework and Milestones.

The payment models that payers are applying to SIM practice sites are aligned with a continuum of APMs established by the Health Care Payment and Learning Action Network (HCPLAN), a national collaborative of public and private stakeholders working to accelerate the healthcare system’s adoption of effective APMs. Payers are using models within Categories 2 and 3 with an aim to evolve toward Category 4 methodologies during the course of the SIM Initiative. A copy of the HCPLAN framework, and a brief description of each SIM payer’s payment model, can be found in the Addendum to the MOU.

Colorado’s selection as a Round 1 CPC+ region provides additional opportunities and resources to support care delivery and payment reform efforts in the state, which are heightened by Medicare’s participation as a payer. Primary care practice sites are eligible and encouraged to participate in CPC+ and SIM. However, initiatives that are designed to test or identify the most appropriate methods for using value-based payments, particularly those sponsored by CMS, are not intended to be additive to existing payment models. All eligible practice sites selected for CPC+ will receive payment support from payers participating in CPC+, per the requirements of the model. However, practice sites selected for CPC+ that are also selected for SIM will likely not receive additional value-based payments for their participation in SIM, depending on the payer.