With the healthcare industry’s transition to value-based care models, optimal health system performance is redefined as enhancing the experience and outcome of the patient, improving the health of populations, and reducing the per capita cost of healthcare. As a result, states are designing and implementing innovative programs to reform how healthcare is delivered and paid for. Delivery System Reform Incentive Payment (“DSRIP”) Programs are a critical component of the evolving landscape of Medicaid delivery service reform. As part of federal Section 1115 Medicaid demonstration waiver programs, DSRIP provides funding that states may use to support hospitals and other healthcare and social service providers in improving how they provide care to Medicaid beneficiaries. The goal of DSRIP is to improve health and transform care delivery for the state’s Medicaid population through the integration and coordination of care across provider specialties and care settings, as well as increase the quality of and access to behavioral health services. Following the passage of the Affordable Care Act in 2010, the federal government approved the first DSRIP initiatives in California. As of February 2018, ten states are using Section 1115 waivers to implement DSRIP initiatives.
In January 2017, the Centers for Medicare and Medicaid Services (CMS) approved the state of Washington’s request for the Section 1115 Medicaid demonstration waiver, through which the state will provide performance-based DSRIP funding to regionally-based Accountable Communities of Health (ACHs). Today, at the start of their second DSRIP year, Washington’s ACHs will begin to execute their project plans. As Washington gets underway with project implementation and outcomes tracking, understanding DSRIP efforts in other states, such as New York, is critical.
Deep Dive: New York State DSRIP
Washington’s DSRIP program is modeled closely after New York’s DSRIP program, which is soon entering its fourth year. In April 2014, the federal government approved New York’s Medicaid waiver request, providing $8 billion in funding over five years. New York proposed an ambitious initiative designed to achieve a 25% reduction in avoidable hospitalizations through transforming the state’s healthcare system. New York’s DSRIP goals include increasing health access for underserved and low-income patient populations, improving disease management programs for targeted chronic conditions, enhancing collaboration across providers with robust population health and care management infrastructure, and developing a reformed value-based payment system for Medicaid managed care beneficiaries. Through DSRIP, New York is shifting from fee-for-service to value-based care models, with an increased focus on population health management and the relationship between patient connectivity and outcomes.
In New York, locally-based Performing Provider Systems (PPS) spearhead DSRIP efforts of a particular geographic region to transform the healthcare delivery system. Each PPS was responsible for conducting a comprehensive community needs assessment and developing tailored programs that address healthcare challenges with measurable metrics. To date, more than 5 million Medicaid beneficiaries receive care from more than 100,000 healthcare providers across New York’s 25 PPSs. In 2016, CipherHealth began partnering with various New York DSRIP PPSs to close gaps in care with clinically-validated and evidence-based care plans and comprehensive patient engagement protocols. By surveying low- and non-utilizing Medicaid and uninsured populations, CipherHealth’s integrated patient communication and coordination platform ensured that at-risk patients received the right care, in the right place, by the right provider. CipherHealth’s scalable care management solution empowered DSRIP entities to track and manage referrals amongst community provider networks.
Implications for Washington
New York’s DSRIP initiatives provide important insights that are directly applicable for Washington’s regionally-based Accountable Communities of Health (ACHs). As Washington’s ACHs are just starting their implementation of DSRIP projects and are likely to face similar challenges as New York’s PPSs, ACHs can consider the following lessons learned from New York:
- Develop Data-Driven Insights: Washington’s ACHs may experience limited access to Medicaid claims data, which are critical for identifying at-risk patient populations. When exacerbated by a weak health information technology infrastructure, this may lead to significant challenges around measuring patient outcomes and completing DSRIP reporting on behalf of the region. Thus, it is vital for both the state of Washington and regionally-based ACHs to invest in robust analytics platforms that support the development of value-based payment foundations and implementation of new data-intensive care models.
- Manage Implementation Processes: Similar to New York’s PPSs, Washington’s ACHs will bring providers and partners together to align regional needs and priorities, projects and actions taken, and investments. Since there is a significant administrative lift involved in reaching DSRIP initiatives, ACHs must be prepared to dedicate the time and resources necessary to ensure long-term success. This includes developing education and stakeholder engagement; IT, reporting, and funds flow infrastructure; legal and financial administration; project selection, implementation, and management; and identifying and funding new services to empower partners in achieving their DSRIP goals. Although initial phases of DSRIP projects focus on building infrastructure, it is important to develop these processes with a focus on the long-term measurement and improvement of clinical processes and value-based payment models.
- Scale Care Coordination: Washington’s ACHs will need to integrate multiple provider types across the care continuum to optimize project design, implementation, and funds flow. Since care management services and providers traditionally operate in silos, DSRIP entities must establish effective integrated care management systems with partners. Washington’s ACHs need to face interoperability issues head-on in order to effectively coordinate care and promote collaboration across different regional providers. With New York experiencing significant challenges around establishing financial incentives for different DSRIP providers, it is crucial for Washington to develop clearly-defined roles for each partner type, expected activities, appropriate metrics and outcomes, and reimbursement methodology to promote interoperable communication and documentation systems.
In this era of value-based care, successful transformation of the healthcare safety net at the system and state levels requires trusted partnership across the care continuum. Healthcare organizations across the country have developed collaborative partnerships with CipherHealth to improve access, quality, and coordination of care for at-risk patient populations by enhancing care transitions between healthcare systems and community support services.
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