Medicaid Redesign Team
Q: What is the MRT Waiver Amendment?
A: The MRT Waiver Amendment will allow the state over five years to reinvest $8 billion in federal savings generated by Medicaid Redesign Team (MRT) reforms to implement an action plan to save and transform the state’s health care system, bend the Medicaid cost curve, and assure access to quality care. The $8 billion reinvestment includes $6.42 Billion for Delivery System Reform Incentive Payments (DSRIP) – including DSRIP Planning Grants, DSRIP Provider Incentive Payments, and DSRIP Administrative costs.
Q: How does the Waiver Amendment relate to the Medicaid Redesign Team?
A: Established by Governor Cuomo in January 2011, the MRT brought together stakeholders and experts from throughout the state to work cooperatively to both reform New York State’s health care system and reduce costs. The MRT was charged with addressing underlying health care cost and quality issues in New York’s Medicaid program to craft a first year Medicaid budget proposal, as well as develop a multiyear reform plan.
The MRT waiver amendment is an agreement that allows the state to reinvest over a five-year period $8 billion of the $17.1 billion in federal savings generated by MRT reforms. This reinvestment will lead to system transformation that will preserve essential safety net providers across the state and increase access for all New Yorkers to high-quality health care.
The MRT waiver amendment will enable New York to fully implement the groundbreaking MRT action plan to permanently restructure our health care system and continue to make New York a national model.
Q: What is DSRIP?
A: Delivery System Reform Incentive Payment (DSRIP) Program. DSRIP is the main mechanism by which New York State will implement the Medicaid Redesign Team (MRT) Waiver Amendment.
DSRIP’s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over 5 years. Up to $6.42 billion dollars are allocated to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health.
Q: What is considered avoidable hospital use?
A: Avoidable hospital use encompasses not only avoidable hospital readmissions, but also inpatient admissions that could have been avoided if the patient had received proper preventive care services
Q: How long does the DSRIP program last? What’s a DSRIP year?
A: The DSRIP program is a 5-year program which included one year for planning which ended 3/31/15. Year 1 began 4/1/15.
Q: How were the submitted DSRIP Project Plan applications reviewed and evaluated for selection?
A: The state developed a standardized application review tool that the DSRIP Independent Assessor used to review DSRIP Project Plans and to ensure compliance with all terms, conditions and protocols agreed to between CMS and the state. The review tool defined the relevant factors, assigned weights to each factor, and included a scoring for each factor. Each factor addressed the anticipated impact of the project on the Medicaid and uninsured populations consistent with the overall purpose of the DSRIP program.
After DSRIP Project Plans were submitted by Performing Provider Systems in December 2014, the Independent Assessor conducted an initial screen to ensure that they met the minimum submission requirements.
The Independent Assessor used the review tool to score all submitted DSRIP Project Plans. After scoring, the state convened a panel of non-conflicted relevant experts and public stakeholders with significant health care transformation experience. The panel had the opportunity to accept, reject, or modify the Independent Assessor’s recommendation.
The Independent Assessor then forwarded the panel’s recommendations to the New York State Commissioner of Health.
Q: What is the role of the Independent Assessor?
A: The DSRIP assessor’s tasks include, but are not limited to: Creating an application and application review tool; Creating a process for a transparent and impartial review of all proposed project plans; Reviewing all proposed Project Plans and making project approval recommendations to the state using CMS-approved criteria; Assembling a Project Plan application review panel based on standards set forth in the DSRIP STCs; Convening a series of DSRIP learning collaboratives to share best practices and receive assistance in implementing DSRIP projects; Conducting a transparent and impartial mid-point assessment of project performance during the second year to determine whether the DSRIP project plans merit continued funding or need plan alterations; Assisting with the ongoing monitoring of performance and reporting deliverables for the duration of the DSRIP program.
Performing Provider System
Q: What is a Performing Provider System?
A: The entities that are responsible for creating and implementing a DSRIP project are called “Performing Provider Systems”, abbreviated “PPS”. Performing Provider Systems are providers that form partnerships and collaborate in a DSRIP Project Plan. PPSs include both major public hospitals and safety net providers, with a designated lead provider for the group. Safety net partners can include an array of providers: hospitals, health homes, skilled nursing facilities, clinics & FQHCs, behavioral health providers, community based organizations and others.
Q: What is required of a DSRIP Performing Provider System?
A: It is important to understand that DSRIP payments are made based upon performance. A PPS will be required to perform a community assessment of need, identify DSRIP strategies that are most consistent with addressing that need, develop a Project Plan incorporating those strategies, implement that Project Plan and monitor milestones and metrics to ensure the implementation is successful. There are certain strategies that will be required of all PPS. It is expected that at the end of the DSRIP Program, the health care delivery system for Medicaid members and other New Yorkers will look fundamentally different, with greater focus on high quality ambulatory care and a de-emphasis on hospital inpatient and ED care, helping to meet the state goal of reducing avoidable hospital use, including emergency department and inpatient, by 25%.
DSRIP Project Valuation
Q: What is DSRIP Project Valuation?
A: The DSRIP project valuation was calculated by the state with the assistance from the Independent Assessor. The maximum valuation for a project was calculated based on the projects chosen, the external valuation benchmark, the application score and the number of Medicaid beneficiaries attributed to each project.
The maximum application value represents the highest possible financial allocation a Performing Provider System can receive for their plan over the duration of their participation in the DSRIP program. Performing Provider Systems may receive less than their maximum allocation if they do not meet metrics and/or if DSRIP funding is reduced because of the statewide penalty.
Q: What are the criteria for achieving incentive payments?
A: These reports will serve as the basis for authorizing incentive payments to Performing Provider Systems for achievement of DSRIP milestones.
In the broader context of Medicaid redesign, one of the core goals of MRT was to end Medicaid fee-for service by moving all populations and services into managed care. Managed care organizations can help the state in achieving its DSRIP goals by aligning payments to the PPS and by making sure that Medicaid beneficiaries have access to the full spectrum of health services that produce better health outcomes.
Project Advisory Committee
Q: What is the Project Advisory Committee?
A: Each emerging Performing Provider System (PPS) was required to form a Project Advisory Committee (PAC). The PAC advises Performing Provider Systems on all elements of their DSRIP Project Plans and should include representation from each of the PPS partners as well as workers and/or relevant unions. The PACs were a requirement for the DSRIP Design Grant application and are expected to be in place over the duration of the DSRIP program.
Q: What is the scope of the Project Advisory Committee?
A: The PAC serves as an advisory entity within the PPS that offers recommendations and feedback on PPS initiatives. The PAC should be involved in the various facets of developing a PPS’s DSRIP Project Plan and then engaged in the implementation and oversight of the Project Plan.
PAC meetings/conference calls serve as forums to share and review proposals as well as discuss ideas that will affect the PPS and its workforce. PACs may choose to form sub-committees around various issues or projects, but sub-committees should attempt to maintain their representativeness of the PAC stakeholders. PACs should meet no less than once a month during the DSRIP planning phase and no less than once a quarter during the implementation and oversight phases.
Community Needs Assessment
Q: How were the results of the Community Needs Assessment used to inform project selection?
A: Each project a Performing Provider System selects must be responsive to a thorough community needs assessment that ties to the DSRIP goals of system transformation and reducing avoidable hospital use, including emergency department and inpatient.
Domains, Strategies & Projects
Q: What are the DSRIP Project Plan, Domains, Projects and Strategies?
A: A DSRIP Project Plan is the overall plan that a Performing Provider System submits to the state. The project plan is composed of at least 5 projects, but no more than 11 projects, based upon projects chosen from a predetermined list.
There are four Domains in DSRIP that represent groupings of project milestones and associated metrics. The four Domains are:
Domain 1 – Project progress milestones – measurement on completion of project plan Domain 2 – System transformation milestones – measurement of system transformation Domain 3 – Clinical improvement milestones – disease focused clinical improvements Domain 4 – Population-wide strategy implementation milestones – Prevention Agenda improvements
Q: How does the state define non-utilizing and low-utilizing Medicaid members?
A: Non-utilizing members are those which are enrolled in Medicaid, yet do not use any services in a given year. Low-utilizing members are those which the state defines as utilizing three or fewer services per year and have little to no connectivity with their PCP or care manager.
Q: What is DSRIP Member Attribution?
A: Member attribution refers to how Medicaid beneficiaries are assigned to Performing Provider Systems. Members are assigned to a given PPS using geography, patient visit information, and health plan PCP assignment. Additionally, patient visit information is used to establish a “loyalty” pattern based on where most of the member’s services are rendered.
Q: What happens if a partner drops out of the DSRIP process due to financial issues?
A: Financial sustainability is a key end point that the PPS will need to attain. It is expected that the transformation of the health care system will result in changes in provider mix, some increases and some decreases. These should be well understood based upon the comprehensive community needs assessment and considered in the developing of projects. A PPS should do its best to try to limit the risk of partners leaving the PPS due to financial issues by (1) allocating DSRIP performance funds within the PPS to aid partners in this situation, as well as (2) help those providers set up adequate restructuring plans to secure financial sustainability over the course of DSRIP and beyond.
Additionally, PPS governance plans must address how it proposes to manage lower performing / financially distressed members within the PPS network. This plan must include progressive sanctions prior to any action to remove a member from the performing provider system. Unless the partner organization closes or there is some other extreme circumstance, PPSs will not be able to alter their partner lists for valuation purposes. A PPS may add partners at a state-chosen time, but no more than once a year.
Q: Within a PPS network, how much autonomy does a PPS have in distributing funds?
A: A PPS has the autonomy to allocate performance funds how it best sees fit, as long as at least 95% of performance payments go to safety net qualified partners and no more than 5% go to non-qualifying safety net partners.
The PPS Lead must establish a budget and funding distribution plan that specifies how DSRIP funds received will be distributed among the participating providers in the PPS to incentivize providers to reach DSRIP performance goals.
Q: What is the AHI PPS?
A: Across the state, Performing Provider Systems (PPS) were formed as a collaboration between partners to implement DSRIP at a regional level. The AHI PPS represents a nine county, 11,000 square mile region (Clinton, Essex, Franklin, Hamilton, Warren, and Washington Counties, and portions of Fulton, Saratoga and St. Lawrence). Its activities impact a population of 700,000.
DSRIP projects are intended to transform the health care delivery system. The AHI PPS network selected 11 DSRIP projects that span all sectors of health care, including primary care and behavioral health, and all destinations on the care continuum, from CBOs to hospitals to long term care settings.
Q: What types of AHI PPS agreements exist?
A: The AHI PPS Terms of Participation agreement outlines the broad terms of engagement. This agreement is relevant to all partner types, regardless of their level of participation in any particular project. There are no dollars attached to the Terms.
The AHI PPS Master Participant Agreement is a contract that includes Exhibits (scope of work for each project). This agreement is tailored to the specific role of the signing provider organization.
Q: I’m a Community-Based Organization. Should I be paying attention to DSRIP?
A: The DSRIP model is based on the concept that housing, poverty and behavioral health are connected to emergency room usage. Many individuals don’t have a primary care physician, but they have ties to a community-based organization (CBO). As community-based care brings treatment to the patient, a requirement of DSRIP is to increase collaboration in patient care between CBOs and traditional providers, including hospitals.
Health Information Sharing
Q: What is the best way to share health information with AHI?
A: As an AHI PPS partner, your organization has signed a Business Associates Agreement (BAA) with AHI. A “business associate” is a person/entity that performs functions or activities involving the use or disclosure of protected health information (PHI). HIPAA requires assurance in writing (in the form of a contract) between business associates of their commitment to appropriately safeguard PHI. Such assurances safeguard the PHI obtained, created, or received on behalf of one another in performance of contractual obligations.
The Privacy Rule generally requires covered entities to take reasonable steps to limit use and disclosure of protected health information (PHI) to the minimum necessary to accomplish the intended purpose. Protected health information refers to demographic information, client or patient contact information of any kind, medical history and results, all dates of service or upcoming appointments, insurance information, and other data that a healthcare professional collects to identify an individual and determine appropriate care.
Even though the transmission of PHI in either direction between AHI and your organization is permissible under a signed dual BAA, the transmission must be secure to reduce the risk of a breach. As per our dual BAA, PHI should be transmitted to AHI encrypted and never through regular email.
Regular email transmits information in an electronic and unprotected form. Once the message is sent, it is communicated over the internet in an unencrypted fashion. If the email were unintentionally sent to the incorrect recipient or intercepted by any other person, the unintended recipient or intervening party would likely be able to read the message.
Files containing PHI should be encrypted and, sent by secure email, using an encryption product such as Zix or Barracuda. Please contact [email protected], or your organization’s Compliance Officer, with questions.
Definition of Terms
|CBO||Community Based Organizations|
|CHW||Community Health Worker|
|CMO||Care Management Organization|
|DEAA||Data Exchange Application and Agreement|
|DOH||Department of Health|
|DSRIP||Delivery System Reform Incentive Payment|
|HARP||Health and Recovery Plan|
|MAPP||Medicaid Analytics Performance Portal|
|MDW||Medicaid Data Warehouse|
|NYS||New York State|
|NYS DOH||New York State Department of Health|
|PHI||Personal Health Information|
|PPS||Performing Provider System|
|RHIO||Regional Health Information Organization|
|SIM||Salient Interactive Miner|
|SUD||Substance Use Disorder|
Source: NY State Department of Health.