On April 14th 2014 Governor Cuomo finalized terms with the federal government to create New York State’s version of the Delivery System Reform Incentive Payment (DSRIP) Plan. DSRIP provides approximately 8 billion dollars to transform the healthcare delivery system in New York. The 8 billion dollars is derived, in theory, from the savings generated by the state’s Medicaid Redesign Team (MRT). DSRIP is a federal program that is currently operating in 6 states. While the federal funding streams are similar, the implementation and scope of the program vary significantly from state to state as is explained in a Kaiser Issue Brief.
While the New York State DSRIP program operates on both the local and state level, all funding is tied to performance. The statewide goal of DSRIP is to “achieve a 25 percent reduction in avoidable hospital use over five years.” This would obviously necessitate a major transformation in the state’s health care infrastructure and workforce.
Even as DSRIP could conceivably effect almost all aspects of the health care delivery system in the state, it feels both ubiquitous and absent to the doctors we represent. On the one hand all long term planning and funding questions at the hospitals are answered with references to DSRIP. Furthermore the DSRIP website and program is incredibly detailed and data driven. And yet, on the other hand, there is lack of clarity concerning exactly how and when these transformations will be put into place by the front line providers, many of whom are unaware that the program even exists.
Each summer the United Hospital Fund holds a conference on New York State’s Medicaid program. This year’s conference “Medicaid in New York: Transforming the Delivery System” featured a key note address from Jason Helgerson, Medicaid director and deputy commissioner in the Office of Health Insurance Programs of the New York State Department of Health entitled “MRT Update—Progress to Date, DSRIP, and the Road to Value-Based Payment.” Both the conference and the presentation provide a good opportunity to assess the current state of DSRIP.
The goals of DSRIP originate with the 2011 MRT report, which set up an action plan still in effect today. It was clear in this report that the state would be seeking the waiver with the goal of ending “ the state’s Medicaid fee-for-service system and replacing it with a comprehensive, high-quality and integrated care management system that will lower costs and improve health outcomes.”
As Helgerson makes clear in his report, payment reform and delivery reform are intimately related. He refers to delivery reform and payment reform as different sides of the same coin. According to Helgerson’s presentation “By DSRIP Year 5 (2019), all Managed Care Organizations must employ non-fee for-service payment systems that reward value over volume for at least 80-90% of their provider payments.” This transition would most likely represent the most radical transition for providers in the state. The state’s Medicaid program spends 59 billion dollars annually. Few providers remain outside of its reach.
DSRIP is state controlled but locally run. DSRIP works by local Medicaid providers coming together to create a Performance Provider System (PPS) which in turn select their goals from a state provided menu of 44 options. While a PPS has great flexibility to both select and decide how it will reach its goals the funding stream is still tied to the safety net system. As the web site explains “ A PPS has the autonomy to allocate performance funds how it best sees fit, as long as 95% of performance payments go to safety-net qualified partners and the remaining 5% go to non-qualifying safety net partners.”
The largest PPS is led by The Health and Hospital Corporation (HHC) which, for example, has seven goals in its application including “Decrease potentially avoidable emergency room visits” and “Actively engage the uninsured and low- and non-utilizing patients in care before they become sick.” All the applications include a community needs assessment as well as a description of the governance structure and stake holder involvement. The applications were reviewed by an independent assessor who graded the applications and provided comments.
According to Crains, HHC’s award from DSRIP will be up to 1.2 million dollars if they are able to reach all their goals. Dr. Christina Jenkins, who leads HHC’s PPS OneCity Health, explains the system only will receive the maximum award “should our 200-plus partners consistently meet performance standards and do our share to help transform health care delivery in New York City.”
Perhaps the key feature of DSRIP is the insistence of the program to have measurable data driven results that are tied to the allocation of funds.
The DSRIP Performance and Reporting Metrics provide the clinical data that is being used throughout the state and broken down by region.
In so far as this is a state program the data driven component will also lead to standardization of care. In Helgerson’s presentation he explains accountability by making this explicit “Providers are held to common performance standards and timelines; funding is directly tied to reaching program goals.”
This point is picked up in a Heath Affairs evaluation of DSRIP authored by Gusmano and Thompson. They write, “Inevitably, performance-based accountability systems raise issues of whether key metrics distort providers’ behavior, causing them to ignore important but less measurable quality dimensions.”
While this is certainly a concern, the DSRIP program is so big with so many different moving parts, governance structures, metrics and stake holders that it is hard to assess the system as a whole at this time, except to state that the devil is in the details. And who got to create and pick the details.