Preventing a DSRIP Power Struggle: A call for clarity over who’s in charge

By Patrick Pilch and Arthur Webb

As New York’s Medicaid reform initiative continues to unfold and evolve, a major issue is surfacing and needs addressing. The interplay between Medicaid enrollees in managed care and those being impacted under DSRIP threatens to create confusion among Medicaid recipients and providers about who is in charge. Communication and outreach may break down in the midst of a massive effort to improve it, and care management may end up at cross-purposes.

The reform initiative, known as the Delivery System Reform Incentive Payment (DSRIP) Program, may prove to be the most effective agent of healthcare change that we have seen in a long time. New York state is reinvesting $6.42 billion in federal Medicaid funds over the next five years to transform its healthcare safety net system. But the interplay between Performing Provider Systems (PPSs) and managed care organizations (MCOs) must be addressed.

Let’s step back and discuss. DSRIP is designed and incentivized as a collective approach to system re-design. A comprehensive collaboration among and between providers/community partners is geared to improving performance on defined measures related to the appropriate use of services. Incentive payments to PPSs will be based on measureable progress on a series of process and outcome measures associated with the individual projects.

The overall goal of DSRIP is to help achieve the goal of reduced avoidable hospitalizations. At the heart of the initiative is changing the way patients or Medicaid enrollees receive care and improving their health statuses and their utilization of services.

While Medicaid MCOs, in the parlance of managed care, own the lives, DSRIP is supposed to change the health care utilization patterns of those patients attributed to each lead PPS. Attribution is the process used in DSRIP to assign a member to a Performing Provider System.

Both MCOs and PPSs are driven by person-centered models for improving care. But in reality, MCOs are risk-based entities operating within specific payments, and PPSs are driven by incentives based on project performance. PPSs are not payers in the strict sense, but will use DSRIP funding to dangle the carrot in front of providers to improve performance. From the start, however, payments are based on realizing milestones.

What will this look like? Anticipating future-state models is essential to defining the answer.

Looking at the opportunities to prevent a potential breakdown of roles, we would suggest that every PPS should have a special committee and an initiative to meet and coordinate the PPS with all respective MCOs to review or execute the following:
  • Clarify the network of providers
  • Clarify messages to Medicaid recipients
  • Organize consumer interface(s)
  • Clarify messages to providers
  • Specify and integrate care management and enrollee tracking
  • Agree on tracking performance of each PPS and on who takes credit for performance
  • Select the right data to collect and analyze
  • Coordinate project management of each PPS
  • Coordinate payment reform around the value-based payments
  • Implement processes to assess risk and to measure outcomes, PPS performance achievements and the total cost of person-centered care
The levels of complexity between MCOs and PPSs are very deep and require a systematic approach to ensure that the consumer gains access to quality care, understands what is going on, and has access to information that is helpful and culturally relevant. Moreover, aligning incentives and objectives among PPSs and MCOs can help achieve the goals of the DSRIP and, ultimately, create value through the right access, the right care and meaningful savings for reinvestment.