Numerous healthcare industry observers have noted that the opportunities being afforded patient care organization leaders under state Medicaid programs are becoming more and more numerous and robust. Indeed, one area that’s seen a great deal of activity in recent years is around Delivery System Reform Incentive Payment (DSRIP) programs and other Medicaid Delivery Transformation Section 1115 Waiver programs, which are working to expand Medicaid eligibility and clinical services for low-income residents in participating states. In New York state, up to $6.42 billion is allocated to the state’s DSRIP Performing Provider Systems, with payments based on achieving performance improvement results in system transformation, clinical management and population health.
On Tuesday at HIMSS18, being held at the Sands Convention Center in Las Vegas, Joseph G. Conte, executive director of the Staten Island Performing Provider System (SI PPS), one of the 25 PPS in New York, shared with his audience how he and his colleagues have been achieving New York state’s DSRIP project goals, and what they’ve learning from their experiences so far; and he was joined by his organization’s technology partner, who shared insights on the technology infrastructure involved.
“Let me talk to you a little bit about the Medicaid design project, about DSRIP,” Conte told his audience. “New York state is the eleventh state in the country involved in Medicaid redesign, following the lead of California, Massachusetts, and several other large states. $7.4 billion was the agreed-upon amount, working with CMS [the federal Centers for Medicare and Medicaid Services], to create a transformative strategy to redesign Medicaid in New York state. So for 6 million people at $60 billion per annum,” he said, describing the number of New York state residents who are Medicaid recipients, and the annual cost of their healthcare, “CMS and Medicaid have a lot at stake. CMS paid for half of the $7.4 billion.”
Conte told his audience, “This is really a disruptive time for providers, healthcare systems, and patients as well—everything we are used to, is changing over time. The DSRIP program is funded over five years, and it really is a value-based program, to the extent that money must be earned in every period, to receive distributed funds. We have about 75 partners—major hospitals, nursing homes, FQHCs, etc.” And one key focus, he noted, has been the social determinants of health. Broadly speaking, he added, 180,000 of the 500,000 residents of Staten Island are potentially affected by this work.
As for data and information technology, Conte told his audience, “Early on, we recognized that identifying a partner to create a business intelligence platform was very important, and that working with old claims data would not provide the BI we needed. And we found a great partner in SpectraMedix”—the East Windsor, N.J.-based SpectraMedix, a data analytics company that specializes in helping providers transition to value-based payment models. “And the Department of Health recognized early on that their partnership was important in helping us to transform care delivery. Bringing in EMS data, getting information from school health, from all the clinical partners in the community, is incredibly important. And when you’re in an at-risk environment, that is absolutely essential to be successful.”
“CMS and the New York Department of Health agreed on about 60 metrics” that would be used in this program to evaluate outcomes, Conte reported; and, in relation to those metrics, he said, “We’ve been extremely successful in the first several years. Among the gains: “We’ve been able to double the amount of reversible preventable ER use, including around substance abuse.”
Speaking of his company’s technology partnership with SI PPS, Raj Lakhanpal, M.D., CEO of SpectraMedix, told the audience, “In DSRIP, you have lead providers and lead partners, and other partners.” In the Staten Island initiative, Lakhanpal said, “They all started giving data, and that gave us a very robust platform.” What’s more, he said, “The dirty secret in data analytics is that 90 percent of the work involves cleaning, normalizing, and compartmentalizing data. That was very helpful. And then the analytics that were produced, and then the project management office could look at the data and say, these are my projects, these are the metrics we need to address, and to incent.”
In all that, Conte told the audience, “Hot-spotting and geo-mapping have been important. We’ve found out where there have been disconnects between services and the need for services. For example, we discovered that, while the north part of the island had nearly all of the substance abuse clinics, the patients in need of that treatment mostly lived on the south side of the island.”
One of the things that Conte and his colleagues did was to leverage EMS (emergency services/ambulance) data, to address the “frequent flyers”—individuals who literally were accessing medical care in emergency departments as many as 200 times a year. Clearly, Conte said, these people were over-using EDs relative to their levels of care need. Identifying those individuals, and connecting them with care management, was a major step. The same principle applied to mapping the high level of incidence of urgent interventions among school-aged children with asthma, relative to the availability of school-nurse care. With geo-mapping, he said, “You can identify areas that are lacking in key services. And in creating maps of the population, we can filter in on specific conditions, and if we were able to hover over a specific area within a specific map, we have three years of claims data, and can figure out utilization, including hospitalization, medications, etc. And we can filter by demographics, by types of chronic illness etc.”
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