DSRIP Financing of Medicaid:

TX, NY and CALISA CHAN-SAWIN, CONSULTANT

EVAN KING, EVP, COPE HEALTH SOLUTIONS

WHAT IS DSRIP?

DSRIP stands for “Delivery System Reform Incentive Payment.”

A Medicaid effort operated under a Section 1115 Medicaid waiver program that provides provider financial incentives to:• Support delivery systems changes to meet the triple aim;• Address gaps in care delivery;• Develop local care coordination & transition protocols;• Improve operations; and,• Increase care capacity and population health.

States leverage federal dollars with a match. Budget Neutrality rules apply.

DSRIP IS FUNDAMENTALLY AN INCENTIVE PAYMENT MODEL. FFS AND MANAGED CARE PAYMENTS STILL HAPPEN. DSRIP PROGRAMS:INCENTIVE PAYMENTS FOR MEETING RELATIVE PROGRESS MEASUREMENTS, GROWING MORE DIFFICULT OVERTIME.SOME STATES ALLOW PARTIAL RECOGNITION FOR PARTIAL ACHIEVEMENT; OTHERS DO NOT. PAYMENTS IN EARLY YEARS ARE GENERALLY FOR PROCESS MEASURES; OUTCOME MEASURES IN LATER YEARS.BEYOND IMPROVED HEALTH OUTCOMES, GOALS INCLUDE:

◦ Better IT integration◦ Provider integration (health & social services)◦ Clinical redesign

PROVIDING INCENTIVES FOR INFRASTRUCTURE & OUTCOMES

Process Metrics

Outcome Metrics & Avoidable

Hospitalization$

Time

Population Health Measures

HOW DO DSRIP PAYMENTS WORK?

DSRIP STATES (IMPLEMENTED)*CA MA TX KS NM NJ NY

Program Participants: Public Public & Private Providers

Hospitals Only X X X X

Health Care Service Providers X X**

Health & Social Service Providers X

Standardization:

Menu of Projects X X X X X

Shared Metrics & Milestones Some X X X

Projects Developed for:

Individual Providers X X X X X X X

Groups of Providers X X

Tie to Other State or CMS Goals:

Public Health Measures X X

Payment Reform X X***

Approved: Nov2010

Dec 2011

Dec2011

Dec2012

Jul2013

Aug 2013

Feb2014 * Arizona’s program was never implemented. Florida and Oregon operate DSRIP-like programs, but don’t seem to be considered full DSRIP by CMS.

** New Jersey hospitals encouraged (not required) to work with downstream providers and share payments.*** New York has a linked statewide 25% reduction in avoidable hospitalization goal that reduces all provider payments if the entire state does not reach that goal.

COMPARING DSRIP PROGRAMS NATIONALLY

COMPARISON OF DSRIP CA, TX & NY

©2015 CARADIGM. CONFIDENTIAL.

California Texas New York

Program Title Delivery System Reform Incentive Program (DSRIP)

Delivery System Reform Incentive Pool (DSRIP)

Delivery System Reform Incentive Payment (DSRIP) Program

Waiver Approved November 2010 December 2011 February 2014

CMS Approval of DSRIP Framework

March 2011 Sept 2012 Protocols still in development

CMS Approval of Individual Plans

March 2011 June 2013 Jan-Mar 2014

Duration 5 Years 5 Years 5.5 YearsFederal Funding Available

$3.3B $5.7B $6.9B

Participating Entities 21 Public Hospitals

20 Regional Healthcare Partnerships (330 public & private providers)

20-40 Performing Provider Systems (thousands of public & private providers)

DSRIP Category Title

1. Infrastructure Development

2. Innovation and Redesign

3. Population-Focused Improvement

4. Urgent Improvement in Care

5. LIHP HIV Transition

1. Infrastructure Development2. Program Innovation and

Redesign3. Population-Focused

Improvement4. Urgent Improvement in

Care

1. Overall Project Progress 2. System Transformation 3. Clinical Improvements4. Population-Wide Strategy

Implementation

Project Menu Size 298 Milestones 1,322 Projects, varying

milestones44 Projects with specific milestones

EVOLVING DSRIP PROGRAMS

SHOWING PROGRESS: CHOOSING THE RIGHT METRICS/POPULATIONS CAN BE CHALLENGING

◦ Patient care and health outcome measures may take longer to achieve than anticipated

◦ Achievability of certain metrics need to be tied to a realistic view of your population

DATA, REPORTING AND TIMELINES.

◦ Reporting timeless were a little over 60 days apart◦ Lack of electronic health records, and the dependence

on paper record system, posed a challenge for many public hospitals (CA)

◦ Limited data sharing capabilities made reporting and care coordination extremely difficult (NY, TX)

WORKFORCE CAPACITY

◦ Current staff took on additional DSRIP responsibilities with no/little additional resources.

◦ As new care team models and protocols were created, organization and retraining of staff (including upstream/downstream providers) became burdensome without dedicated funding streams

DSRIP CHALLENGES

LEADERSHIP:

◦ Executive sponsorship critical for buy-in and alignment with strategic goals

◦ Understand the State & CMS’s goals for DSRIP and align with them

◦ Identify champions for each project◦ Create multiple communication channels to ensure

everyone understand the strategic direction and moving towards the same goals

STRATEGIC PLANNING:

◦ Create dedicated clinical teams for each project◦ Be cautious and thoughtful in selecting goals – they

should be a reach but attainableDEDICATED ATTENTION TO DETAIL:

◦ Create a PMO or have dedicated staff track DSRIP policy, projects and progress

◦ Dedicate resources to IT, Workforce Retraining and Clinical Staff

◦ Plan up front how your org & partners will share data for reporting & clinical decision making

◦ Institute a process for rapid cycle evaluation, learning and dissemination of information

LESSONS LEARNED

CURRENT 1115 WAIVER EXPIRED IN OCTOBER 2015, BUT EXTENDED UNTIL DECEMBER 31, 2015. NEW WAIVER AGREEMENT IN CONCEPT WITH CMS.

oTotal initial federal funding in the renewal is $6.218 billion.oPossible additional federal funding in GPP to be

determined after year one. MAJOR COMPONENTS INCLUDE:

oGlobal Payment Program (GPP) for services to the uninsured in designated public hospital systems (DPH). oDelivery system transformation and alignment

incentive program for DPHs and district/municipal hospitals (DMPH), known as PRIME (Public hospital Redesign and Incentives in Medi-Cal). ($3.3B over 5 years for DPHs, $466.5M over 5 years for DMPHs)oDental transformation incentive program ($750M over

5 years)oWhole Person Care Pilot (WPC) program which would

be a county-based, voluntary program to target providing more integrated care for high-risk, vulnerable populations. ($1.5B in federal funds over 5 years)oIndependent assessment of access to care and

network adequacy for Medi-Cal managed care beneficiaries.oIndependent studies of uncompensated care and

hospital financing.

PRIME, DSRIP 2.0

Thank you!LISA CHAN-SAWIN, LISA@WEBSAWIN.COM

EVAN KING, EKING@COPEHEALTHSOLUTIONS.ORG