Implementing NYS Healthcare Reform Initiatives. Greg Allen, NYS Medicaid Policy Director

Transcription

1 Implementing NYS Healthcare Reform Initiatives Greg Allen, NYS Medicaid Policy Director

2 MRT Waiver Amendment: NYS DSRIP Program overview en 2

3 NYS DSRIP Program: Key Goals Transformation of the health care safety net at both the system and state level. Reducing avoidable hospital use and improve other health and public health measures at both the system and state level. Ensure delivery system transformation continues beyond the waiver period through leveraging managed care payment reform. Near term financial support for vital safety net providers at immediate risk of closure.

4 DSRIP Program Principles

5 NYS DSRIP Plan: Key Components o Key focus on reducing avoidable hospitalizations by 25% over five years. o Statewide initiative open to large public hospital systems and a wide array of safetynet providers. o Payments are based on performance on process and outcome milestones. o Providers must develop projects based upon a selection of CMS approved projects from each of three domains. o Key theme is collaboration! Communities of eligible providers are required to work together to develop DSRIP Project Plans.

6 PERFORMING PROVIDER SYSTEMS (PPS): Local Partnerships to Transform the Delivery System Partners should include: Hospitals Health Homes Skilled Nursing Facilities Clinics & FQHCs Behavioral Health Providers Home Care Agencies Community Based Organizations Practitioners and Other Key Stakeholders Responsibilities must include: Community health care needs assessment based on multi-stakeholder input and objective data. Building and implementing a DSRIP Project Plan based upon the needs assessment in alignment with DSRIP strategies. Meeting and reporting on DSRIP Project Plan process and outcome milestones. en 6

7 May Performing Provider Systems Key Public Hospital led PPS Safety Net (Non-Public) led PPS

8 Five Themes of DSRIP 1.Collaboration, Collaboration, Collaboration!!! 2. Project Value drives a) Transformation # and types of projects b) # of Medicaid members served (attribution) c) Application Quality 3. Performance Based Payments 4. Statewide Performance Matters 5. Lasting Change a) Long-Term Transformation b) Health System Sustainability

9 The DSRIP Vision: Five Years in the Future How The Pieces Fit Together: MCO, PPS & HH Other Providers MCO* PPSs ROLE: -Insurance Risk Management -Payment Reform -Hold PPS/Other Providers Accountable -Data Analysis -Member Communication -Out of PPS Network Payments -Manage Pharmacy Benefit -Enrollment Assistance -Utilization Management for Non-PPS Providers -DISCO and Possibly FIDA/MLTCP Maintains Care Coordination ROLE: -Be Held Accountable for Patient Outcomes and Overall Health Care Cost -Accept/Distribute Payments -Share Data -Provider Performance Data to Plans/State -Explore Ways to Improve Public Health -Capable to Accept Bundled and Risk-Based Payments HH #1 HH #2 Other PPS Providers ROLE: -Care Management for Health Home Eligibles -Participation in Alternative Payment Systems *Mainstream, MLTC, FIDA, HARP & DISCO 9

10 Statewide Performance and Accountability o Beginning in Year 3, limits on funding available and provider incentive payments may be subject to reductions based on statewide performance. o Statewide performance will be assessed on a pass or fail basis for a set of four milestones. o The state must pass all four milestones to avoid DSRIP reductions. o If penalties are applied, CMS requires the state to reduce funds in an equal distribution, across all DSRIP projects.

11 DSRIP Finance Framework

12 May DSRIP Performance Milestones P4P Annual improvement targets will use a methodology of reducing the gap to the goal by 10%. Example - If the baseline data for a measure is 52 percent and the goal is 90 percent, the gap to the goal is 38 percent. The target for the project s first year of performance would be 3.8 percent increase in the result (target 55.8 percent). Each subsequent year s baseline would be re-set with a target using the most recent year s data. Performing Provider Systems may receive less than their maximum allocation if they do not meet metrics and/or if DSRIP funding is reduced because of the statewide penalty. High performance fund/awards for being above the statewide goal, or closing the gap to goal by 20%

13 Setting the Annual Improvement Targets & High Performance Goals

14 May The DSRIP Challenge Transforming the Payment System DSRIP will be as much about payment reform as about delivery reform Financial and regulatory incentives drive a delivery system which realizes cost efficiency and quality outcomes: value

15 6/2/ State Solution Performance Dashboards From Aggregate Measures

16 6/2/2015 4

17 6/2/2015 5

18 6/2/ State Solution Performance Dashboards to Member detail

19 Questions? DSRIP 19