Will “Instant Businesses” Be Able to Deliver the Promises of DSRIP?

By Patrick Pilch and Arthur Webb

All eyes in the public health arena are currently on New York. The state has become a laboratory for healthcare redesign as it takes on the challenges of very quickly overhauling care delivery models to implement Delivery System Reform Incentive Payment (DSRIP) programs.

The ambitious goals focus on realigning care around a series of discrete bundled services or accountable care organizations to reduce unnecessary or avoidable hospital admissions and ER visits for Medicaid, underinsured and uninsured populations. We anticipate that provision of services will shift from hospital inpatient settings to ambulatory, post-acute, home or behavioral health provider settings—which will create a platform for comprehensive financial and operational restructuring of hospitals.The collective experiences and lessons learned from this execution and implementation phase will provide insight and extend to other risk-based models in Medicare and commercial offerings nationwide.

A Steep Learning Curve for “Pop-Up Businesses”

As much as the state is guiding the efforts of Performing Provider Systems (PPSs, or the entities collaborating on DSRIP projects), minimal guidance has been provided to address a situation that simultaneously requires adherence to new guidance and creative innovation. In some ways, these PPSs are akin to “pop-up businesses” that are evolving in ways similar to the “doc-in-a-box” model of primary care. These organizations are being formed very quickly to take on the immensely complex task of implementing DSRIP.

Furthermore, much is required of them to succeed in implementation. Organizational processes such as governance, workforce, financial sustainability, cultural competency, IT systems and processes, population health management, clinical integration, performance reporting, practitioner engagement, etc., each come with their own specific milestones. Organizations that can innovatively synthesize these efforts are likely to be the most successful.

Challenged to Lead by Example

Several challenges offer New York an opportunity to lead the country in care delivery innovation: 
  1. Project management is the center of DSRIP and the basis for performance and incentive payments. Making sure project management is well organized and open to evolution creates stability without stifling innovation.
  2. Care management is a core function that connects attributed lives with programs and the primary care system. The connectivity with managed care organizations becomes an essential linkage to reduce fragmentation. Preparing care management requires staffing, training and deploying care managers who are armed with actionable patient lists and a care management workflow tool.
  3. Workforce management is a major obstacle. How to engage and leverage the workforce and coordinate the shift from hospital-centric services to a coordinated healthcare network presents multiple challenges that should be addressed head-on.
  4. Performance management will demand getting the metrics right and developing actionable analytics. Not only is there a need for sufficient IT capacity but also the brain power to provide the analytics to govern performance.
  5. Appointing quality leaders will be key to successful execution. Quality leadership must be in place across 25 PPSs, a challenge even with New York’s robust workforce.
  6. All stakeholders must accept that innovation will replace current norms for delivering and coordinating care. Separating failures from lessons learned will advance the success of the PPS and create models for study and further implementation.
Dr. W. Edwards Deming, renowned statistician, author and consultant, was known in part for his “Deming Cycle for Continuous Improvement,” which include the steps of “Plan, Do, Study, Act.” These steps summarize the DSRIP process nicely. With the implementation phase commencing in New York, we will now advance from theory and planning to real-world execution and all that comes with it.

In modeling successful DSRIP implementation for the rest of the country, innovation is required of New York payers and providers, and execution is the key.