NYS DSRIP Overview Todd Ellis, DHA Corey M. Zeigler, MBA, CHCIO November 2016
DSRIP: A Mechanism to Transform Medicaid Delivery Delivery System Reform Incentive Payment (DSRIP) programs are a key mechanism to transform Medicaid delivery to improve patient care. DSRIP main goals are based on the Triple Aim principles: DSRIP programs incentivize hospitals and providers to prevent emergency visits and manage chronic disease in low-income and/or Medicaid patients. DSRIP is a mechanism to fund Medicaid transformation projects driven by performance-based payments. The funding is validated through reporting of DSRIP metrics. 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 1
DSRIP Reporting and Outcome DSRIP and DSRIP-like States are required to meet and report a series of metrics rooted in quality. Some key metrics are as follows: Clinical outcomes depends on the project selected or provider measures (DSRIP-like) Ambulatory admission rates Population health metrics diabetes, asthma, HIV, etc. Processes of care metrics - antidepressant medication management Patient experience scores - patient surveys Access measures - same day appointment at ambulatory clinics or solo Patient-Centered Medical Home (PCMH) practitioner For specific details on quality of care metrics and payment reform in each state, refer (source below) to the Appendix of State Experiences Designing and Implementing Medicaid DSRIP, published by the National Academy for State Health Policy Source: https://www.macpac.gov/publication/state-experiences-designing-and-implementing-medicaid-delivery-system-reformincentive-payment-dsrip-pools/ 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 2
Medicaid 1115 Waivers and DSRIP Delivery System Reform Incentive Payments (DSRIP) fall under the broader Medicaid 1115 Waiver. Section 1115 demonstration Waivers were approved by the Centers of Medicare and Medicaid Services (CMS) and authorize states to partake in research and demonstration projects that target the goals set by the Department of Health and Human Services. Section 1115 Key Facts: The Section 1115 Waiver is designed to expand Medicaid eligibility, provide services not typically covered by Medicaid and/or use innovative delivery systems to improve care, increase efficiency, and reduce cost. Some, but not all, states are implementing such change through DSRIP. Demonstrations must be budget neutral to the federal government. This means that the federal government cannot spend more with the waiver in place than the projected amount without any waiver. DSRIP Initiatives promote collaboration, supporting innovation, and bringing attention to social services 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 3
DSRIP Waiver and State Protocol Approval Process Most DSRIP states go through this process for their respective projects. (DSRIP-like programs differ in the final step) 1115 Waiver Special Terms and Conditions Approved State DSRIP Protocols Approved Provider DSRIP Plan Approved DSRIP Project Implementation Begins Source: www.macpac.gov 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 4
The Focus of DSRIP Waivers DSRIP waivers focus on 4 main areas with an increasing focus on clinical and population improvements over time Infrastructure Development (Process) System Redesign (Process) Clinical Outcome Improvements (Outcomes) Population Focused Improvements (Outcomes) Source: Kaiser Family Foundation, Issue Brief 2014 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 5
DSRIP Nationwide 14 states have submitted DSRIP/DSRIP-like waivers: 11 Approved, 3 Pending Kansas Washington Massachusetts New York Alabama (pending) Arizona 2010 2011 2012 2013 2014 2015 2016 2017 California Texas New Jersey New Mexico* Tennessee** New Oregon* (pending) Hampshire *DSRIP-like programs: Do not use projects but do fund providers base on performance North Carolina (pending) ** DSRIP-like implementation part of greater reform plan 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. DSRIP Like DSRIP DSRIP Pending 6
DSRIP Nationwide Washington and Arizona s DSRIP plans have been approved for FY17 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 7
Overview: New York State DSRIP NYS DSRIP Overview: $8 Billion in federal savings generated by the Medicaid Redesign Team (MRT); $6.42 Billion for DSRIP; $500 Million for the Interim Access Assurance Fund (IAAF) $1.08 Billion for other Medicaid Redesign purposes Will promote community-level collaborations and focus on system reform Goal is to achieve a 25% reduction in avoidable hospital use over 5 years Performing Provider Systems (PPS): will include both major public hospitals and safety net providers Projects domain include: Project progress milestones System Transformation milestones Clinical Improvement milestones Population-wide strategy implementation milestones Future plans: The focus for Year 2 will be to focus on preparing for Value Based Payment (VBP) implementation A VBP Bootcamp learning series is being conducted throughout the state Source: CAPH.org and safetynetinstitute.org 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 8
Overview: New York State DSRIP 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 9
Technologies Driving NYS DSRIP Program Success Continues State Level: Medicaid Analytics Performance Portal (MAPP) is a performance management tool and supports care management efforts for the State s Health Home (HH) program Salient Interactive Miner (SIM) is an analytical tool for Medicaid claims data - high ER utilization and high risk patients population DSRIP Dashboard assist with quality & outcomes monitoring, including the DSRIP measures performance portal Technology RHIO Level: Data and Analytics used for connectivity, data collection, data formatting, claims management, patient matching, and expanding security to facilitate more enriched data exchange. Each RHIOs current Master Patient Index (MPI) is used to link files on patient demographic data Data Integration: RHIOs receive multiple data sources and have operational processes in place for data cleansing, standardization, and matching required for clinical integration. PPS Level: Data and Analytics: Utilization of EHR, MAPP, and RHIO dashboards for PHI stratification; Utilization of statistical and geographical software for identification of high-risk population by zip codes Data Integration: PPS networks connected to their respective RHIO, HIE, Care Management and Population Health Management (PHM) systems for care coordination State agency tools such as SPARCS, MAPP, and SIM data pulled by PPS networks for aggregated PHI data and for validation on PHI statistics Patient Level: Patient Portal provides a secured bidirectional communication between patient and providers, which allows patients to view and download their clinical summary, schedule appointments, and view test results. Patient Portals are part of patient continuity of care. 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 10
Care Management Models used NYS PPS Care Management Models: Types of Models: Centralized Model is used by NYS PPS networks where care management, patient centered healthcare services, and billing are administered locally including co-located clinics with the same governance. The only outside service is interoperability with a RHIO or HIE Decentralized Model is used by PPS networks with outsourcing services such as billing, care management from other agencies or PPS networks Combination of Centralized and Decentralized model is widely used by PPS networks where some healthcare services are administered locally by the PPS providers while others are performed by other providers One successful example of the duality is PPS network partnering with community health centers to perform STD testing/prevention services, and social services such as diabetes education 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 11
Greater New York Hospital Association (GNYHA) Care plans: GNYHA works with New York state health plans and PPS networks to facilitate care coordination using claims data via PPS EHRs for these services areas: Primary care Mental Health Dental Vision Pharmacy 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 12
Common Challenges Change takes time Cultural change is hard DSRIP is a down payment on transformation Bundled payment vs. FFS, ACOs, CCOs, Organizing the DSRIP leads Stakeholders Buy-in is crucial State governor to hospital executives Relevant roles Clear message main goals PHM Implementation Barriers No universal platform for PHM Compatibility with all EHR and HIE Bi-directional implementation among EHRs, PHM, HIE Data retrieval and storage is challenge who owns the data? Valid data identifiers or markers must be used by all integrated systems Patient consent Structure Clinical and IT personnel need to collaborate Not all PPS networks are technologically equal due to lack of funds Internal and external DSRIP partners (government and non government agencies) are necessary to accomplish the Triple Aim goals 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 13
Effective Methods for VBP Environment Training Ensure medical and billing staff are aware of the changes Ensure staff, including PPS partners, is trained on VBP or new revenue cycle systems and models Medical Plans Ensure bundles are discussed and negotiated before implementation Claims data are report back to the PPS network Clear communications on bundle payments Implementation Ensure billing system is compatible to existing EHR All PPS partners are integrated with the new VBP systems 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 14
Additional Resources Medicaid Waiver 1115 by State: https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-andwaiver-list/waivers_faceted.html NYS DOH DSRIP Program Overview and Resources: http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/://www.medicaid. gov/medicaid/section-1115-demo/demonstration-and-waiverlist/waivers_faceted.html 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. 15
SAMARITAN MEDICAL CENTER DSRIP FIDUCIARY LEAD DSRIP 101 16
A CULTURE SHIFT Current System Future System To each their own One succeeds, all succeed One fails, all fail
The Healthcare Revolution Acute Care Specialty Care Acute Care Specialty Care Prevention & Primary Care More Dr. s, RN s, Care Managers, Etc. Prevention & Primary Care The secret to change is to focus all of your energy, not on fighting the old, but on building the new. ~ Socrates Avoidable ED & hospital admissions reduced by 25%
100% 90% 0% % of DSRIP Project Funding by Year Pay for Reporting vs. Performance 15% 80% 70% 60% 50% 40% 100% 85% 45% 65% 85% 30% 20% 10% 0% 55% 35% 15% 2015 2016 2017 2018 2019 Pay for Reporting Pay for Performance Milestones & Tasks, Provider Engagement, Patient Engagement, Quality Metrics, Achievement Values (AVs)
Community Need - A Regional Snapshot Rural, Tug Hill Seaway (Jeff, Lewis, St. Law) Total population = 262,650 Land-Mass/ Population Density - 5,224 square miles of land mass. Population density is 50 persons per square mile Community healthcare system supports Fort Drum Army Installation (40,000 TRICARE beneficiaries) Only US Installation, with a Division of Soldiers & families, without a hospital on base
North Country Initiative (NCI) Governance Structure 21
Key Ingredients 2. System Transformation 3. Clinical 11 Projects 1. Organizational Domains 4. Population Health 2ai 2aii 2aiv 2biv 2di 3ai 3bi 3ci 3cii 4aiii 4bii 22
Domain 1 - Organizational Focus Areas Governance Board, Committees, Agreements Practitioner Engagement, Clinical Integration & Population Health Financial Stability and Sustainability, Funds Flow Workforce - Increase Access to Care, Care Coordination IT Systems & Processes MU, PCMH, HIE Cultural Competency & Health Literacy Patient Understanding Aligning Incentives Performance Reporting & Moving to Value Based Payment 23
Four Pillars of Clinical Integration supporting Physician Practices 24
Project Selections 25
2.a.i - Create Integrated Delivery System (IDS) (PHM, HIE, EHR, HH, Pt. Eng) 2.a.i: Expand access to primary care providers and engage patients in the IDS through outreach and navigation activities, leveraging community health workers, peers and culturally competent community-based organizations as appropriate. Connection to the HIE, secure direct messaging. 26
Public Health Reporting & Monitoring (3-5 Yr View). Inputs Public payer claims and census data, population surveys Outputs Mortality rates, socioeconomic factors and community-based disparities by county, by hospital, by service line Who would use Public Health, Community- Based Organizations, Health Planners, and Hospital strategic and marketing planners. Aggregation Level Patient Specific Information Health Information Technology Tools Disease Registry (1-2 Yr View) Health Information Exchange (HIE) (Secondary Now View) Electronic Health Record (EHR) (Now View) Inputs From Hospitals Lab and demo data, dx and treatment From clinics/practices Prob lists, demo data, dx and treatment Outputs Clinical quality and population health measures and actionable patient lists for follow-up Who would use Public Health, primary care practices/clinics and Hospital quality and readmissions teams. Clinically Integrated Network Physician Leadership. Clinical Analytics Inputs Pharmacy Data From Hospitals Lab and demographics data, radiology imaging, reports and other transcribed reports From clinics/practices (future planned development) Problem lists, demographics, diagnosis and treatment Outputs Real-time results delivery to providers and patient summaries from all sources Who would use Primary, Specialty, Emergency and Hospital Providers at the point of care Secondary source Inputs Clinical and demographical data entered either directly by providers and other clinical and administrative staff or data from the HIE Outputs Legal patient record, clinical decision support and billing Who would use Primary, Specialty, Emergency and Hospital Providers at the point of care - Primary source
Major DSRIP, ACO & CIN HIT Initiatives Tentative Timeline for Project Duration HIE (3 Months) PCMH (12 Months) EHR Implementation (9 Months) EHR Optimization (6 Months) ICD-10 PHM Implementation (6 Months) PHM Optimization (6 Months) PHM Maintenance (Ongoing) MU Stage 1 (9-12 Months) MU Stage 2 Telemedicine (6 Months) Blood Pressure Monitors 2 Months Assess Privacy Security Assess Privacy Security Assess Privacy Security April 1, 2015 Jan 1, 2016 Jan 1, 2017 Dec 31, 2017
Tell Help Do Other Speed Impact on Internal Practice Resources Cost* *Cost is mitigated and often much lower due to resources being local
2.a.ii Patient Centered Medical Home (PCMH) (Primary Care, Care Coordination, Warm Hand Off) 2.a.ii: Ensure that all staff are trained on PCMH or APC models, including evidence-based preventive care and chronic disease management. Ensure staff are trained to implement behavioral health screenings (PHQ2/9 and SBIRT). 31
2.a.iv 2.b.iv 2.d.i 3.a.i 3.b.i 3.c.i DSRIP Projects Create a Medical Village Using Existing Hospital Infrastructure Create Medical Village s throughout our region to allow patients to access multiple healthcare functions for outpatient care & services in one convenient location, a one-stop-shop for today s busy lifestyle. Offering comprehensive healthcare service, patient s needs will be more appropriately served by their provider. Care Transition Intervention Model to Reduce 30-Day Readmissions for Chronic Health Conditions The primary focus of this project will be aimed at increasing the patients awareness and understanding of follow-up care & supports once discharged from the care of the hospital. Implementation of Patient Activation to Engage, Educate and Integrate the uninsured & low/non-utilizing Medicaid populations into Community Based Care Focusing to engage & activate these individuals to utilize primary & preventative care services, will improve our region's population health management through patient activation, financially accessible healthcare resources & partnership with primary & preventative care services. Integration of Primary Care and Behavioral Health Services The objective of this project is to integrate behavioral health & substance abuse services with essential primary care services, ensuring coordination of care. Evidence Based Strategies for Disease Management in High Risk/Affected Populations (Adults Only) Cardiovascular Conditions Physicians will utilize evidence-based medicine when healthcare decisions are made for their patients with cardiovascular conditions, ensuring highquality care reflecting the interests, values, & needs to effectively manage their patients. Key Factors Include: Clinical Care Goals, Medication Adherence Goals, Patient Supports & Reminder Goals. Evidence Based Strategies for Disease Management in High Risk/Affected Populations. (Adult Only) Diabetes Ensuring clinical practices in the community and ambulatory care setting using evidence based strategies to improve management of diabetes. Including improvement of practitioner population management, increase patient self-efficacy & confidence in self-management & implementing diabetes management evidence based guidelines. 3.c.ii Implementation of Evidence-Based Strategies in Community to Address Chronic Disease-Primary and Secondary Prevention Projects. (Adults Only) Develop community resources to assist patients with primary & secondary preventive strategies to reduce risk factors for diabetes & improve the long term consequences of diabetes & other co-occurring chronic diseases. 4.a.iii Strengthen Mental Health & Substance Abuse Infrastructure across Systems (Focus Area 3) Collaboration among leaders, professionals & community members working in MEB (Mental, Emotional & Behavioral) health promotion to address substance abuse & other MEB disorders. Addressing chronic disease prevention, treatment & recovery & strengthening infrastructure for MEB health promotion & MEB disorder prevention. 4.b.ii Increase Access to High Quality Chronic Disease Preventative Care & Management in Both Clinical & Community Settings Deliver of high-quality chronic disease preventive care & management can prevent much of the burden of chronic disease or avoid many related complications.
Performance Reporting Population Health Management (Disease Registry) NCI will implement and utilize disease registry population health management tool Receive data from electronic health records and have the capability to exchange CMS data Data utilized to create a comprehensive dashboard for real-time monitoring of performance against metrics (DSRIP quality metrics, HEDIS measures, PQRS, utilization analysis), to support & assist practices to meet quality metrics Performance Logic NCI will monitor provider & organizational performance in PPS-wide project tracking software, Performance Logic to proactively identify areas of risk and/or underperforming providers Quality assessment will be performed by the Medical Management Committee The PMO will disseminate performance gaps to enable transparency & performance monitoring through proactive event alerts, control charts & reports that will inform business, operational & clinical improvements amongst all PPS partners. Performance data distributed to the governing body & project workgroups will inform improvement activities & identify opportunities for population based activities to improve the health of a targeted population. MAPP NCI, will use the NYS DOH MAPP PPS specific Performance Measurement Portal for the monitoring of performance on claims-based, non-hospital CAHPS DSRIP metrics and DSRIP population health metrics. The Performance Portal will show our baseline performance, benchmarks, and the gapto-goal targets per metric. 33
What s Next? The REAL Work - CHANGE Agreements and Contracting Entity Specific Implementation Plan Templates Organizational and Project Activities Measuring Outcomes Getting Paid for Value
Things to keep in mind Cross Functional (linking of tasks across projects) Leveraging existing resources Performing Provider System Project Management Office Support The importance of tracking and documentation (i.e. trainings, screen shots, etc.) RFPs Communication and Transparency NCI Newsletter 5 Fast Facts DSRIP in a Nutshell/Fact Sheets NCI Website North Country Health Compass Website Committee Involvement 35
HOW DOES IT MAKE YOU FEEL?
QUESTIONS? NCI Director: Brian Marcolini bmarcolini@northcountryinitiative.org (315) 755-2020 ext. 31 DSRIP Director: Erika Flint EFlint@NorthCountryInitiative.org (315) 755-2020 ext. 26 Regional CIO: Corey M. Zeigler czeigler@fdrhpo.org (315) 755-2020 ext. 11