Delivery System Reform Incentive Payment Program & The End of AIDS: Collaborative, Integrated, and Quality-driven Care

Transcription

1 Delivery System Reform Incentive Payment Program & The End of AIDS: Collaborative, Integrated, and Quality-driven Care Albany Medical Center HIV Breakfast Club, February 5, Objectives 1)Understand and state the overall goal of the Delivery System Reform Incentive Payment (DSRIP) Program. 2)List 3 components of the HIV projects within DSRIP. 3)Understand and list the 3 levels of Value-Based Payments and how these could be applied to the HIV subpopulation in NY. 2 1

2 Outline History and goals of the DSRIP Program Performing Provider Systems (PPSs) DSRIP Projects Ending the AIDS Epidemic DSRIP Program and HIV Projects Population Health DSRIP Performance and Outcome Measures Value-Based Payments 3 Case History 45 year-old male is newly diagnosed with HIV infection based on testing after referral from NYS partner notification services History of bipolar disorder HIV risk factor is MSM Has excess alcohol consumption, and uses marijuana and methamphetamine CD4 cell count is 350 cells/cmm HIV RNA is 66,000 copies/ml 4 2

3 DSRIP Program Focus Linkage to out-patient Medical and Behavioral Health care, for both Mental Health and Substance Use needs Goals include education on the benefits of antiretroviral therapy & importance of adherence to therapy and ultimately, complete viral suppression Assessment of his own partner notification needs Assessment of both his mental health and substance use needs Retention in out-patient Medical and Behavioral Health care Coordinated, collaborative care with a care manager Co-located, integrated services, especially for Behavioral Health and 5 Primary Care MRT Waiver Amendment In April 2014, Governor Andrew M. Cuomo announced that New York State and CMS finalized agreement on the Medicaid Redesign Team (MRT) Waiver Amendment. Allows the state to reinvest $8 billion of the $17.1 billion in federal savings generated by MRT reforms for 6.3 million members. The MRT Waiver Amendment will: Transform the State s Health Care System Bend the Medicaid Cost Curve Assure Access to Quality Care for all Medicaid members 6 3

4 Medicaid Redesign Initiatives Have Successfully Reduced Costs NYS Statewide Total Medicaid Spending (CY ) $55 $50 $45 Tot. MA Spending (Billions) $40 $35 $ # of Recipients Cost per Recipient Calendar Year ,267,573 4,594,667 4,733,617 4,730,167 4,622,782 4,657,242 4,911,408 5,212,444 5,398,722 5,598,237 5,805,282 6,311,762 $8,469 $8,472 $8,620 $8,607 $9,113 $9,499 $9,574 $9,443 $9,257 $8,884 $8,520 $8,223 7 Medicaid Redesign Initiatives Have Successfully Brought Back Medicaid Spending per Member to 2003 Levels $10,000 $9,500 Tot. MA Spending per recipient $9,000 $8,500 $8, Calendar Year # of Recipients Cost per Recipient ,267,573 4,594,667 4,733,617 4,730,167 4,622,782 4,657,242 4,911,408 5,212,444 5,398,722 5,598,237 5,805,282 6,311,762 $8,469 $8,472 $8,620 $8,607 $9,113 $9,499 $9,574 $9,443 $9,257 $8,884 $8,520 $8,223 Source: NYS DOH OHIP DataMart (based on claims paid through April 2015) 8 4

5 DSRIP Program s Key Components Overarching goal is to reduce avoidable hospital use ED and inpatient by 25% over 5+ years of DSRIP Built on the CMS and State goals in the Triple AIM Improving Quality of Care Improving Health Reducing Costs 9 Reducing Avoidable Hospitalizations This will be done by: Developing integrated delivery systems Removing silos Improving transitions of care Enhancing primary care Enhancing community-based services Integrating behavioral health and primary care 10 5

6 DSRIP Accounts for 80% of Waiver Amendment Dollars and is the Foundation for Better Care, Less Cost Person-Centered Transparent Collaborative Accountable Value Driven Improve member care & experience through a more efficient, person-centered and coordinated system. Decision-making process takes place in the public eye and processes are clear and aligned across providers. Collaborative process reflects the needs of the communities and inputs of stakeholders. Providers are held to common performance standards, deliverables and timelines. Focus on increasing value to the member, the community, payers and other stakeholders. Better care, less cost 11 The Performing Provider Systems (PPSs) 12 6

7 Performing Provider Systems and Local Partnerships Partners should include: Hospitals Health Homes Social Service Departments & Local Government Units Behavioral Health Providers Skilled Nursing Facilities Clinics & Federally Qualified Health Centers Home Care Agencies Physicians/Practitioners Other Key Stakeholders Community health care needs assessment based on multi-stakeholder input and objective data. Building and implementing a DSRIP Project Plan based upon the needs assessment in alignment with DSRIP strategies. Meeting and reporting on DSRIP Project Plan process and outcome milestones. 13 The DSRIP Process Independent Assessor reviewed and scored the applications 25 Performing Provider Systems (PPSs) selected Project Approval Oversight and Oversight Panel (PAOP) met initially in February 2015 Reviewed scores Made recommendations Recommendations sent to NYS Health Commissioner Zucker and approved Submitted to CMS for review and approval PAOP met again with PPSs in November 2015 Upstate and January 2016 in NYC 14 7

8 October 2015 The 25 Performing Provider Systems in New York 15 Key Public Hospital led PPS Safety Net (Non-Public) led PPS 15 Physician Networks Primary Care Physicians are critical to the attribution process. 16,000+ Primary Care Physicians in the 25 PPS networks 49,000+ non-pcps in the 25 PPS networks Include physician specialists, nurse practitioners, dentists, noninstitutional long-term care providers, and other professional service providers 16 8

9 Consenting for DSRIP: An Opt-Out Process NYS is modeling the DSRIP consent process on the Medicare ACO model which is an opt-out model, i.e., unless member formally opts out of DSRIP data sharing, they are considered participating in data sharing. To opt out means to elect NOT to permit the sharing of any PHI and other Medicaid data held by the state with the PPS and its partners. The recipient is not opting out of DSRIP. The member who opts out will not have his/her Medicaid data shared with the PPS lead and partners. A person can opt out or opt in for data sharing at any time. 17 DSRIP Projects 18 9

10 DSRIP Domains and Project Requirements Project implementation is divided into four Domains for project selection and reporting: Domain 1 Overall Project Progress This domain houses the project s process measure for all three domains Domain 2 System Transformation* 2.a.i Creating an Integrated Delivery System 2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions 2.b.vi Implementing transitional supportive housing services All PPSs selected at least two (and up to four [or five*]) projects from Domain 2 19 *Only PPS approved to conduct project 2.d.i will be able to select a maximum of five projects from Domain 2 (and 11 projects in total). All other PPS will maintain the opportunity to choose up to four projects from Domain 2 (and up to 10 projects in total). Domain 2: System Transformation Projects A. Create Integrated Delivery Systems 2.a.i Create Integrated Delivery Systems that are focused on Evidence-Based Medicine / Population Health Management 2.a.ii Increase certification of primary care practitioners with PCMH certification and/or Advanced Primary Care Models (as developed under the NYS Health Innovation Plan (SHIP)) 2.a.iii Health Home At-Risk Intervention Program: Proactive management of higher risk patients not currently eligible for Health Homes through access to high quality primary care and support services 2.a.iv Create a medical village using existing hospital infrastructure 2.a.v Create a medical village/alternative housing using existing nursing home infrastructure C. Connecting Settings 2.c.i Development of community-based health navigation services 2.c.ii Expand usage of telemedicine in underserved areas to provide access to otherwise scarce services B. Implementation of Care Coordination and Transitional Care Programs 2.b.i Ambulatory Intensive Care Units (ICUs) 2.b.ii Development of co-located primary care services in the emergency department (ED) 2.b.iii ED care triage for at-risk populations 2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions 2.b.v Care transitions intervention for skilled nursing facility (SNF) residents 2.b.vi Transitional supportive housing services 2.b.vii Implementing the INTERACT project (inpatient transfer avoidance program for SNF) 2.b.viii Hospital-Home Care Collaboration Solutions 2.b.ix Implementation of observational programs in hospitals D. Utilizing Patient Activation to Expand Access to Community Based Care for Special Populations 2.d.i Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/nonutilizing Medicaid populations into Community Based Care 20 10

11 Electronic Integration for Patient-Centered Medical Homes Use of an electronic health record that meets meaningful use 2 standards Integration into the Regional Health Information Network (RHIO) or Qualified Entity (QE) Hospitals, Medical Practices, Skilled Nursing Facilities and Health Homes Integration into the Statewide Health Information Network of New York (SHIN-NY) 21 The 11 th Project 2.d.i. Engage the Low Utilizers (LU) and Non-Utilizers (NU) among Medicaid enrollees Engage those who are Uninsured (UI) Public System PPSs had the right of first refusal Utilizes the Patient Activation Measure (PAM ) by Insignia 22 11

12 Health Homes Administration of Care Management services for members Oversee outreach, engagement and enrollment into Health Homes of Medicaid members with: 2 or more chronic conditions A single qualifying condition of HIV or Serious Mental Illness (SMI) Each PPS is required to work with the Health Homes. A vehicle for engagement of members for PPSs doing the 11 th Project Low utilizers and non-utilizers of Medicaid, and the uninsured HARP members those with SMI and Substance Use Disorders a priority for Health Home enrollment Home and Community-Based Services (HCBS) available for eligible HARP members Tier I services include employment, education and peer supports services. Tier 2 includes the full array of 1915i-like services 23 Domain 3: Clinical Improvement Projects A. Behavioral Health 3.a.i Integration of primary care and behavioral health services D. Asthma 3.a.ii Behavioral health community crisis stabilization services 3.d.i Development of evidence based medication adherence programs (MAP) in community settings asthma medication 3.a.iii Implementation of evidence-based medication adherence 3.d.ii Expansion of asthma home based self management program programs (MAP) in community based sites for behavioral health 3.d.iii Implementation of evidence based medicine guidelines for medication compliance asthma management 3.a.iv Development of Withdrawal Management (e.g., ambulatory detoxification, ancillary withdrawal services) capabilities and E. HIV/AIDS appropriate enhanced abstinence services within community-based 3.e.i Comprehensive Strategy to decrease HIV/AIDS transmission addiction treatment programs to reduce avoidable hospitalizations development of a Center of 3.a.v Behavioral Interventions Paradigm (BIP) in Nursing Homes Excellence for Management of HIV/AIDS B. Cardiovascular Health 3.b.i Evidence-based strategies for disease management in high F. Perinatal Care risk/affected populations (adult only) 3.f.i Increase support programs for maternal & child health (including high risk pregnancies) (Example: Nurse Family Partnership) 3.b.ii Implementation of evidence-based strategies in the community to address chronic disease primary and secondary G. Palliative Care prevention projects (adult only) 3.g.i Integration of palliative care into the PCMH Model C. Diabetes Care 3.g.ii Integration of palliative care into nursing homes 3.c.i Evidence-based strategies for disease management in high 24 risk/affected populations (adults only) H. Renal Care 3.c.ii Implementation of evidence-based strategies to address 3.h.i Specialized Medical Home for Chronic Renal Failure chronic disease primary and secondary prevention projects (adults only) 12

13 DSRIP Domains and Project Requirements Domain 3 Clinical Improvement CV disease, asthma, diabetes, perinatal care, HIV/AIDS, e.g. 3.a.i Integration of primary care services and behavioral health 3.a.ii Behavioral health community crisis stabilization services 3.d.ii Expansion of asthma home-based self-management program All PPSs selected at least two (but no more than four) projects from Domain 3 Domain 4 Population-wide Strategy Implementation The Prevention Agenda 4.a.ii Prevent substance abuse and other mental emotional disorders 4.b.i Promote tobacco use cessation, especially among low SES populations and those with poor mental health All PPSs selected at least one (but no more than two) projects 25 Ending the AIDS Epidemic 26 13

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15 29 Web Addresses for Ending the Epidemic (EtE) for EtE Dashboards for Ending the AIDS Epidemic in NY State 30 15

16 Defining the End of AIDS Governor Cuomo announced a 3-point plan on June 29, 2014: 1. Identify all persons with HIV who remain undiagnosed and link them to health care. 2. Link and retain those with HIV in health care, to treat them with anti-hiv therapy to maximize virus suppression so they remain healthy and prevent further transmission. 3. Provide Pre-Exposure Prophylaxis (PrEP) for high risk persons to keep them HIV negative GOAL: Reduce the number of new HIV infections to just 750 (from ~3,000) by EtE Blueprint Structure and Content In January 2015, the NYS Ending the Epidemic (EtE) Task Force finalized 44 Committee Recommendations that address HIV-related prevention, care and supportive services. Committee Recommendations were informed by 294 community recommendations and 17 statewide stakeholder meetings. The final Blueprint contained 30 Blueprint Recommendations and 7 Getting to Zero Recommendations

17 DSRIP Project 3.e.i: HIV/AIDS Related Prevention Agenda Intervention Region New York City PPS The NY and Presbyterian Hospital) 33 DSRIP Project 3.e.i. Comprehensive Strategy to decrease HIV/AIDS transmission to reduce avoidable hospitalizations - development of Center of Excellence for management of HIV/AIDS The ultimate goal of both this project and the End of AIDS is consistent, long-term viral load suppression in as many patients as possible. Linkage to care, retention in care and adherence to medication are all core elements of this process The New York and Presbyterian Hospital is the only PPS pursuing this project Model 1 Early Access to and Retention in HIV and HCV Care Scatter Mode Model 2 Center of Excellence Management for HIV/AIDS (including HCV) 34 17

18 DSRIP Project 3.e..i, Model 2 HIV Project Requirements 1 of Identify site location for a Center of Excellence (COE) which would provide access to the population infected with HIV (and/or HCV). Co-locate at this site services generally needed for this population including primary care, specialty care, dental care, behavioral health services, dietary services, high risk prenatal care and buprenorphine maintenance treatment. Co-locate care management services including Health Home care managers for those eligible for Health Homes. Develop a referral process and connectivity for referrals of people who qualify for but are not yet in a Health Home. Ensure understanding and compliance with evidence-based guidelines for management of HIV/AIDS (and HCV) Ensure coordination of care between all available services preferably through a single electronic health/medical/care management record. 35 DSRIP Project 3.e..i, Model 2 HIV Project Requirements 2 of 2 7 Ensure that all PPS safety net providers are actively sharing EHR systems or other IT platforms with local health information exchange/rhio/shin-ny and sharing health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look ups, by the end of DY 3. 8 Ensure that EHR systems or other IT platforms, used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards and/or APCM by the end of Demonstration Year 3. 9 Use EHRs or other IT platforms to track all patients engaged in this project. 10 Seek designation as center of excellence from New York State Department of Health 36 18

19 The NY & Presbyterian Hospital HIV/HCV Center of Excellence Transform three HIV clinics into true Centers of Excellence via: Increased intensive care management/coordination, with RN care managers and practice facilitators Extending care beyond the clinics, using Community Health Workers Behavioral Health (BH) integration, adding BH staff and buprenorphine maintenance program at Chelsea site Transforming testing and adherence, including HCV testing and PrEP Implementing a Rapid HIV Consult Service in the ED that can be activated in triage for HIV positive individuals Expanding hours for same day appointments and walk ins 3 clinic sites serve about 5000 individuals 95% have Medicaid or ADAP Are Designated AIDS Centers and PCMHs Engage with its Health Home 37 Domain 4 Population Health HIV Projects 38 19

20 DSRIP Domain 4 HIV Projects 4.c.i. Decrease HIV morbidity (Focus Area 1; Goal #1) By December 31, 2017, reduce the newly diagnosed HIV case rate in New York by 25% to no more than 14.7 new diagnoses per 100,000 4.c.ii. Increase early access to, and retention in, HIV care (Focus Area 1; Goal #2) By December 31, 2017, increase the percentage of HIV-infected persons with a known diagnosis who are in care by 9% to 7% By December 31, 2017, increase the percentage of HIV-infected persons with known diagnoses who are virally suppressed to 45%. Data Source: NYS HIV Surveillance System 39 DSRIP Domain 4 HIV Projects 4.c.i. Decrease HIV morbidity The New York and Presbyterian Hospital 4.c.ii. Increase early access to and retention in HIV care Bronx Advocates - Bronx-Lebanon Bronx Partner for Healthy Communities - St. Barnabas Hospital, Montefiore Medical Center Brooklyn Bridges - NYU-Lutheran Family Health Centers Community Care of Brooklyn - Maimonides Medical Center Mt. Sinai New York Presbyterian Queens 40 One City Health - NY Health & Hospitals Facilities 20

21 Project 4.c.i & 4.c.ii: HIV & Sexually Transmitted Diseases Related Prevention Agenda Intervention Region New York City New York City New York City New York City New York City New York City New York City New York City PPS Bronx Lebanon Medical Center HHC Facilities Lutheran Medical Center Maimonides Medical Center Mount Sinai Hospitals Group St. Barnabas Hospital The NY and Presbyterian Hospital The NY Hospital of Queens 41 DSRIP Domain 4 HIV Projects: PPSs chose 7 of 12 Sector Projects 1 of 2 1. Decrease HIV and STD morbidity and disparities; increase early access to and retention in HIV care. 2. Increase peer-led interventions around HIV care navigation, testing and other services. 3. Launch educational campaigns to improve health literacy and patient participation in health care, especially among high-need populations, including Hispanics, and lesbian, gay, bisexual and transgender (LGBT) groups. 4. Design all HIV interventions to address at least two co-factors that drive the virus, such as homelessness, substance use, history of incarceration and mental health. 5. Assure cultural competency training for providers, including gender identity and disability issues. 6. Implement quality indicators for all parameters of treatment for all health plans operating in New York State. An example would be raising the percentage of HIV-positive patients seen in HIV primary care settings who are screened for STDs per clinical guidelines

22 DSRIP Domain 4 HIV Projects: PPSs chose 7 of 12 Sector Projects 2 of 2 7. Empower people living with HIV/AIDS to help themselves and others around issues related to prevention and care. 8. Educate patients to know their right to be offered HIV testing in hospital and primary care settings. 9. Promote interventions directed at high risk individual patient, such as therapy for depression. 10. Promote group or behavioral change strategies in conjunction with HIV/STD efforts. 11. Assure that consent issues for minors are not a barrier to HPV vaccination. 12. Establish formal partnerships between schools and/or school clinics, and community based organizations to deliver health education and support teacher training programs. 43 New York State Health Initiatives PREVENTION AGENDA Priority Areas: - Prevent chronic diseases - Promote a healthy and safe environment - Promote healthy women, infants, and children - Promote mental health and prevent substance abuse - Prevent HIV, sexually transmitted diseases, vaccinepreventable diseases, and healthcare-associated infections STATE HEALTH INNOVATION PLAN (SHIP) Pillars and Enablers: - Improve access to care for all New Yorkers - Integrate care to address patient needs seamlessly - Make the cost and quality of care transparent - Pay for healthcare value, not volume - Promote population health - Develop workforce strategy - Maximize health information technology - Performance measurement & evaluation ALIGNMENT: Improve Population Health Transform Health Care Delivery Eliminate Health Disparities MEDICAID DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM Key Themes: - Integrate delivery create Performing Provider Systems - Performance-based payments - Statewide performance matters - Regulatory relief and capital funding - Long-term transformation & health system sustainability POPULATION HEALTH IMPROVEMENT PROGRAM (PHIP) PHIP Regional Contractors: - Identify, share, disseminate, and help implement best practices and strategies to promote population health - Support and advance the Prevention Agenda - Support and advance the SHIP - Serve as resources to DSRIP Performing Provider Systems 44 22

23 Performance and Outcome Measures 45 DSRIP Measure Specification and Reporting Manual: Project 3.e.i Measure Name Specification Version NQF # Numerator Description Denominator Description Performance Goal Achievement Value Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 HIV-AIDS Comprehensive Care: Engaged in Care QARR 2015 NA Number of people who had two visits for primary care or HIV related care with at least one visit during each half of the past year Number of people living with HIV/AIDS, ages 2 years and older 91.8% 1 if annual improvement target or performance goal met or exceeded NYS DOH P4P P4P HIV-AIDS Comprehensive Care: Viral Load Monitoring QARR 2015 NA Number of people who had two viral load tests performed with at least one test during each half of the past year Number of people living with HIV/AIDS, ages 2 years and older 82.7% 1, as above NYS DOH P4P P4P Syphilis Screening QARR 2015 NA Number of people screened for syphilis in past year Number of people living with HIV/AIDS, ages 19 years and older 85.4% 1, as above NYS DOH P4P P4P Cervical Cancer Screening HEDIS Number of women who had cervical cytology performed every 3 years or women, ages 30 to 64 years, who had cervical cytology human HPV co-testing performed every 5 years Number of women, ages 24 to 64 years 83.9% 1, as above NYS DOH P4R P4P Chlamydia Screening (16 24 years) HEDIS Number of women who had at least one test for Chlamydia during the measurement year Number of sexually active women, ages 16 to 24 80% 1, as above NYS DOH P4P P4P Viral Load Suppression NYS DOH NA Number of people whose most recent viral load result was below 200/copies Number of people living with HIV/AIDS TBD 1, as above NYS DOH P4P P4P

24 DSRIP Domain 4 c Projects - HIV Measures Measure Name Projects associated with Measure Numerator Description Denominator Description Measurement Year 0 Data (Data Year) Prevention Agenda 2018 Objective Achievement Value/Payment DY 2-5 Reporting Responsibility Newly diagnosed HIV case rate per 100,000 4.c.i, 4.c..ii, 4.c.iv Number of people newly diagnosed with HIV, regardless of concurrent or subsequent AIDS diagnosis Number of people 19.1 ( ) 16.1 P4R Measure only NYS DOH Newly diagnosed HIV case rate per 100,000 - Difference in rates (Black and White) of new HIV diagnoses 4.c.i, 4.c..ii, 4.c.iv Rate of Black non-hispanics newly diagnosed with HIV, regardless of concurrent or subsequent AIDS diagnosis Rate of White non- Hispanics newly diagnosed with HIV, regardless of concurrent or subsequent AIDS diagnosis 44.4 ( ) 46.8 P4R Measure only NYS DOH Newly diagnosed HIV case rate per 100,000 - Difference in rates (Hispanic and White) of new HIV diagnoses 4.c.i, 4.c..ii, 4.c.iv Rate of Hispanics newly diagnosed with HIV, regardless of concurrent or subsequent AIDS diagnosis Rate of White non- Hispanics newly diagnosed with HIV, regardless of concurrent or subsequent AIDS diagnosis 26.7 ( ) 26.6 P4R Measure only NYS DOH Data Source: NYS HIV Surveillance System 47 DSRIP Domain 4 c Projects - STD Measures Measure Name Projects associated with Measure Numerator Description Denominator Description Measurement Year 0 Data (Data Year) Prevention Agenda 2018 Objective Achievement Value/Payment DY 2-5 Reporting Responsibility Gonorrhea case rate per 100,000 women - Aged years 4.c.iii, 4.c.iv Number of women age diagnosed with gonorrhea Number of women age (2013) P4R Measure only NYS DOH Gonorrhea case rate per 100,000 men - Aged year 4.c.iii, 4.c.iv Number of men age diagnosed with gonorrhea Number of men age (2013) P4R Measure only NYS DOH Chlamydia case rate per 100,000 women - Aged years 4.c.iii, 4.c.iv Number of women age diagnosed with Chlamydia Number of women age ,536.0 (2013) 1,458.0 P4R Measure only NYS DOH Primary and secondary syphilis case rate per 100,000 males 4.c.iii, 4.c.iv Number of men diagnosed with primary or secondary syphilis Number of men 14.8 (2013) 10.1 P4R Measure only NYS DOH Primary and secondary syphilis case rate per 100,000 females 4.c.iii, 4.c.iv Number of women diagnosed with primary or secondary syphilis Number of women 0.5 (2013) 0.4 P4R Measure only NYS DOH Data Source: NYS STD Surveillance System

25 Payment Reform 49 DSRIP Program Finance Framework $ Process Metrics Outcome Metrics & Hospitalizations Population Health Measures Time

26 DSRIP Performance Milestones P4R and P4P P4R Pay-for-Reporting used for the Process Measures in the early years of DSRIP All Domain 4, Prevention Agenda project measurements are P4R P4P Pay-for-Performance used for the Outcome Measures in the later years of DSRIP 51 DSRIP Performance Milestones P4P Annual improvement targets will use a methodology of reducing the gap to the goal by 10%. For example, if the baseline data for a measure is 52 percent and the goal is 90 percent, the gap to the goal is 38 percent. The target for the project s first year of performance would be a 3.8 percent increase in the result (target 55.8 percent). High performance fund/awards available for being above the statewide goal, or closing the gap to goal by 20% 52 26

27 Value-Based Payments - Clinical Advisory Groups Stakeholder meetings with leaders in the field statewide Include technical groups, and those around chronic conditions, like diabetes and cardiovascular disease, and subpopulations of: Members in Health and Recovery Plans (HARPs) Members with HIV/AIDS Members with Intellectual and Developmental Disabilities Members in Managed Long Term Care Plans Typically 3-4 meetings for each group Make recommendations for measures 53 HIV Clinical Advisory Group MCOs and PPSs can Choose Different Levels of Value Based Payments In addition to choosing what integrated services to focus on, the MCOs and PPSs can choose different levels of Value Based Payments: 54 Level 0 VBP Level 1 VBP Level 2 VBP Level 3 VBP (only feasible after experience with Level 2; requires mature PPS) FFS with bonus and/or withhold based on quality scores FFS with upside only shared savings available when outcome scores are sufficient (For PCMH/APC, FFS may be complemented with PMPM subsidy) FFS with risk sharing (upside available when outcome scores are sufficient) Prospective capitation PMPM or Bundle (with outcome based component) Goal of 80-90% of total MCO-provider payments (in terms of total dollars) to be captured in Level 1 VBPs at end of DY5 Aim of 35% of total costs captured in VBPs in Level 2 VBPs or higher 54 27

28 How should an integrated delivery system function? Value-Based Payments Prenatal and Maternity Care Elective Care (Hip-, Knee replacement, ) Integrated Physical & Depression Behavioral Primary Acute Cardiovascular (AMI, Stroke) Care Pneumonia Includes social services Cancer care interventions and Chronic care (HIV, Diabetes, CHF, Hypertension, Asthma, ) community-based prevention activities Multimorbid disabled / frail elderly (MLTC population) Severe BH/SUD conditions (HARP population) Population Health focus on overall Outcomes and total Costs of Care Care for Intellectually/Developmentally Disabled Sub-population focus on Outcomes and Costs within subpopulation/episode Episodic Continuous 55 NY DSRIP Program s Vision Today s Care PCP refers individual to HIV specialist for HIV care, and other sites for Behavioral Health care Acute care is given as next available, and walk-ins are scheduled for another time Care delivered around acute illness, IP hospital stays, and ER visits PCP directs any Care Management Care directed by a single practitioner Medicaid member (or guardian) informs practitioner about what happened when hospitalized in another city Care in DSRIP Program Member sees Mental Health and Substance Use providers at the same place and same day as medical practitioner Open access scheduling accommodates ALL appropriate acute care needs and walk-ins Annual exams and preventive care shift the focus to wellness for Medicaid members in their communities Care Management needs met a priori, and all appointments are coordinated around Care Management Care coordinated by a multidisciplinary team, each member working to the full extent of her/his scope of practice Integrated electronic network enables the practitioner to see the other providers labs, imaging studies and discharge summary 56 28

29 Thank you! Questions? Additional information available at: DSRIP Follow the MRT on Like the MRT on Facebook: Subscribe to our listserv: