In April 2014, New York Governor Andrew Cuomo announced that New York would be implementing a series of Medicaid reforms through a Delivery System Reform Incentive Payment (DSRIP) program. The DSRIP program was designed to promote community-level collaborations focused on system reform. New York is one of nine states to implement the DSRIP program. To be a part of the DSRIP program, safety net providers such as hospitals, health homes, skilled nursing facilities, clinics & FQHCs, behavioral health providers, community based organizations and others providers in specific regions came together to create a Performing Provider System (PPS) network. Those PPS networks then outlined a series of goals aimed at reducing avoidable hospital use by 25% over five years, including inpatient admissions that could have been avoided if the patient had received proper preventative care services.
In New York, twenty-five PPS networks were created and approved to participate in the DSRIP program. To qualify, in short, a PPS network needed to include a public, critical access, or sole community hospital and approximately 1/3 of their patient volume needed to be from Medicaid or uninsured individuals. Through a partnership with the federal government, NY State allocated $6.42 billion to pay directly to the PPS networks over five years for achieving their pre-defined goals. Each PPS network needed to submit a handful of projects/programs spread across three categories:
- System transformation projects such as expanding telehealth coverage, developing co-located primary care services in the ED, or creating transitional supportive housing services.
- Clinical improvement projects such as the integration of primary care and behavioral health services, evidence based strategies for disease management in high risk/affected populations, or the integration of palliative care into nursing homes.
- Population-wide projects such as promoting mental, emotional and behavioral (MEB) well-being in communities, implementing tobacco use cessation programs, or improving sexual education for at-risk populations.
April 2018 marked the start of the fourth year of the DSRIP program. The question is, has it been successful so far?
For the first three years of the program, more than 96% of the allocated DSRIP payments have been made to the PPS networks because the outlined performance metrics were achieved. The PPS networks have shown improvement in preventable hospital readmission, preventable emergency room visits, patient connection to consistent source of primary care, and access to timely appointments. So far, the state has achieved a 16.5 percent reduction in potentially preventable hospital readmissions and a 12.5 percent reduction in potentially preventable ED visits. Moreover, statewide spending for ED continues to decrease – PMPM spending was $25.59 under the target the third year of the program. According to New York State Medicaid Director Donna Frescatore, “We are making monumental progress toward improving care for millions of New Yorkers. While we are on a clear path to success, our work is far from over. In the months and years ahead, we will shift our focus toward improving performance metrics and health outcomes as we work to change the culture of health care.”
Without a doubt, the PPS networks are proving to be successful and the participating hospitals and provider organizations are benefiting financially in terms of direct payments from New York State. However, after 2020, the direct payments will cease, yet the PPS networks will continue to reap the financial benefits for many years to come as a result of the programs and process improvements implemented as part of the DSRIP program, particularly as our healthcare system continues to move toward value based care. Referral management is often mentioned from by the PPS networks in their project plans and roadmaps for success as a key tool in helping them improve care coordination, increase interoperability and boost preventative care compliance. Many of the programs and solutions implemented by these PPS networks, including referral management, can easily implemented by other large provider networks such as ACOs, IPAs, and MSOs.
For more information on the PPS networks and the details on their successful programs to reduce hospital admissions, please visit the DSRIP website.