Looking Back to Look Ahead: NYS DSRIP

The New Year has meant a lot of uncertainty for healthcare providers nationally, as the country transitions to a new administration and prepares for further reform of the healthcare system. For New York State (NYS) Medicaid providers, this uncertainty has been the reality since the early discussions of the 1115 Waiver in NYS.  

Early findings suggest the Delivery System Reform Incentive Payment (DSRIP) Program is “working.” At least in meeting some of the goals it set out to meet three years ago. Early state findings indicate a reduction of avoidable hospitalizations attributable to DSRIP efforts.

Further, with the release of the initial findings for the Mid-Point Assessment, the Independent Assessor (IA) and state have indicated there will be no drastic overhaul of Performing Provider Systems (PPSs) and their infrastructure. The midpoint assessment clearly articulates winners and losers, PPSs that seem to be on track, and those that have struggled in some areas to set the ground work for transformation. However, as the PPSs make the shift from infrastructure to outcomes, working to have real impact on the patients they serve, for now it appears there will be no significant or notable changes.

We do expect, however, a greater sense of urgency by NYS to drive reform and compel PPSs to move fast. The state pushed up the timeline for the Mid-Point Assessment, likely to ensure the PPSs had the recommendations prior to DSRIP Year 3 (DY3), and were in a position to make any required adjustments at this critical time to support future success. By the end of March, PPSs will have had to address the findings of the Mid-Point Assessment and move into DY3 with a new focus and even more urgency.

Mid-Point Assessment Results: What Did We Learn?
The Mid-Point Assessment focused on select areas including:
  • Progress against project implementation milestones
  • Progress on Funds Flow
  • Partner Engagement
  • Financial sustainability (i.e., the transition to value-based payments, or VBP)
Overall, 21 one out of 25 PPSs demonstrated notable deficiencies.

Limited Partner Engagement
A majority of the PPSs are behind on their Partner Engagement goals according to the IA findings. Many PPSs need to shift their focus to engaging network partners in more meaningful ways, especially if a significant impact on outcomes is now required. As future payments to PPSs will increasingly depend on performance and outcomes, partner engagement and care coordination will become ever more important to the success of the PPS.

Stymied Funds Flow
The Mid-Point Assessment found that in many instances, Funds Flow is another way in which PPSs have failed to engage partners. The Project Management Office supporting PPSs and hospitals have received more than 70 percent of DSRIP funds to date across all PPSs. The reasoning for this approach may be because PPSs have focused heavily on funding PMO staffing and infrastructure development; but a lack of Funds Flow to network partners may be impacting their ability to meet downstream project implementation milestones.

Project Implementation
For many of the PPSs, keeping pace with project implementation steps and timelines established at the outset of DSRIP has been difficult. Missed project milestones are likely directly attributable to deficiencies in Partner Engagement and Funds Flow to participating partners to support project implementation efforts.

Financial Sustainability and VBP: Urgency to Change, but Uncertainty About Roles Persist  
The Independent Assessor is recommending that more than two-thirds of the PPSs implement action plans related to Financial Sustainability and VBP. For many PPSs, the transition to VBP and the VBP milestones have taken a back seat, as PPSs focused on meeting minimum requirements to ensure maximum findings for organizational implementation milestones. Further, a lack of clarity around how providers will sustain the achievements of DSRIP through VBP arrangements and a lack of clear understanding of the expectations of the state have slowed movement in some cases. The lack of a universally understood definition of VBP has further hindered progress among PPS partners.

Preparing for 2017 – DSRIP Year 3
For those that have been involved with DSRIP since the planning grant phase, when it was still somewhat of an unknown, DY3, with all the targets and mandatory Project Requirements across all DSRIP milestones, seemed far-off. Now that it is upon us, how PPSs prepare and react entering into this year will be the barometer for their success.

DY3 offers the opportunity to change course and implement lessons learned over the last three years. The challenge of DY3 will be to focus on two things: implementing improvements in care delivery to patients through supporting change at the point of care and an effective transition to VBP. This transition to VBP is the major structural transformation that will define and determine DSRIP success for each PPS.

The state has committed to penalizing Managed Care Organizations and providers who do not meet the timelines and requirements set out in the VBP roadmap. This is because as part of the agreement with CMS, if VBP commitments are not met, CMS will fine the state.

Yet one of the challenges many PPSs are facing is this essential question: What role does the PPS actually play in this transition of the payment system?

Although some PPSs are developing ACOs or IPAs to act as the contracting entity in VBP arrangements in most cases VBP contracting will occur with groups of providers acting independently from the PPS. In fact, these disparate provider groups will likely be a driving force of the transition to VBP.

There remains tremendous uncertainty around the nature of the PPSs’ and the PPS partners’ roles today and in the future. Having developed the infrastructure to support clinical integration, how can PPSs support providers through enabling them with the information (data), best practice clinical protocols, and with the “know how” required to operate in a VBP environment?

In December, the DOH released further guidance on what PPSs are expected to develop as part of the next wave of VBP DSRIP milestones (4-8). This will start with a survey/needs assessment of providers that will need to be completed by the end of March 2017 and a subsequent VBP Implementation plan that will lay out how the PPSs will “support” the adoption of VBP across their networks as well as a VBP education and training plan (including an emphasis on CBOs) (due June 2017). The “old” milestones  where the State had laid out commitments to meeting Level 1, 2 and 2+ VBP arrangements has been replaced by a more vague milestones that do not contain timelines or specifics. The State has now indicated that the VBP plans will set the stage for the next set of expectations and each PPS will have to chart their own course, in conjunction with their partner network, on how they will sustain all of this important work.

Developing a common understanding of VBP across the network and implementing an effective partner engagement strategy will be critical to the future success of the PPSs. There is no ‘one size fits all’ approach, and each PPS, and its network of partners, will require a customized transition plan. The path to success starts with a well written VBP survey, and a hands-on approach to soliciting meaningful data back from PPS partners. Training, communication, and customization by an experienced VBP team will be required to ensure the data and resulting implementation plan are tailored to PPS needs, and are effective at engaging the various partners in the network. The end goal can only be reached with a solid communication and engagement and a strategy that focuses on the long term success of the partner network.