Delivery System Reform Incentive Program [DSRIP] National Academy for State Health Policy
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1 Delivery System Reform Incentive Program [DSRIP] National Academy of State Health Policy October 2014
2 Topics Addressed in this Presentation Ø Background of the New Jersey (NJ) DSRIP Program. Ø Framework of the DSRIP Program-Program Design. Ø Opportunities and Challenges seen thus far. Ø Emerging policy questions. Note: The approach used in this presentation is to focus the discussion at a high level and not burden the session participant with the rigors of detailed Program Funding and Mechanics. Details can be viewed on the NJ DSRIP Website at October
3 Background of the NJ DSRIP Program NJ Objectives DSRIP Program was developed and offered to NJ Hospitals instead of a predecessor funding pool (Hospital Relief Subsidy Fund) that CMS would no longer support through federal financial participation (FFP). With the emergence of health care reform and the Affordable Care Act there is a need to address population health improvement for NJ s low income population. DSRIP was a way to further support the Health NJ 2020 Program. October
4 Background of the NJ DSRIP Program CMS Objectives were to support their three part aim: October
5 Background of the NJ DSRIP Program NJ DSRIP Policy Design Features All 63 NJ Hospitals were eligible to sponsor a DSRIP project including private not-for-profit and for profit hospitals. The all inclusive eligibility for hospitals was an effort to best serve the low income population with the expectation of expanded access under the Affordable Care Act. NJ DSRIP program defined the low income population for eligibility as Medicaid, Charity Care, CHIP, and Medicaid dual eligible. NJ has a robust claims reporting system for both charity care and Medicaid/CHIP patients creating the opportunity for; Comparative project measurement performance and Improvement targets including the design of an attribution algorithm for recipient assignment. October
6 October
7 NJ DSRIP Projects & Stages Chronic disease 8 focus areas and 17 pre-determined Projects: Asthma Cardiac Care Pneumonia Diabetes Behavioral Health Obesity Chemical Addiction/Substance Abuse HIV/AIDS Stage descriptions: Stage 1 Infrastructure development Stage 2 Chronic condition redesign and management Stage 3 Project-specific quality improvements Stage 4 Population-wide quality improvements October
8 Project Stages and Measures Each Demonstration Year [DY] has Pay-for-Reporting [PFR] and/or Pay-for Performance [PFP] stage 3 and 4 measures. There are approximately 100 measures used relying on measure specifications from national measure stewards [e.g. HRSA, NCQA, JC]. Project PFP measures range from 4 to 11 project specific measures. There are approximately 45 stage 4 universal measures. Some measures are calculated through the State Medicaid Management Information System and some are hospital reported through Chart/EHR sources. October
9 Project Measures: Attribution Assignment Low income population recipients are assigned to hospitals using an attribution algorithm with the following features; CMS is most comfortable with attribution models that follow the Medicare Shared Savings Program and/or the Pioneer ACO Program A preliminary prospective assignment that supports patients can be identification, outreach, and engagement with a retrospective application for calculating measures. There are no minimum patient volumes. Uses E&M codes and visits with a 70%/30% weight for recent years. Bases assignment on several settings of care-ed, Clinics, Physicians, FQHCs, and other providers. Initially CMS would not allow the ED to be included as a care setting. A single provider attribution assignment is used. A single patient episode is used. A plurality algorithm using visits determines assignment. October
10 Payment Matrix by Year and Stage October
11 NJ DSRIP Fact Sheet: As of September hospitals submitted and received application approval from the State and CMS. 4 Hospitals later withdrew from the Program for a variety of reasons. Cardiology and Diabetes projects were the most commonly selected projects [40 of the 55 approved projects]. Annual DSRIP program is funded at $166.6 million. Rutgers University will be performing a mid course and summative evaluation of the DSRIP Program Primarily hospital centric project with other project provider partner incentivized participation. DSRIP participation is voluntary. Documents that govern the Program include: 1115 comprehensive Waiver Special Terms and Conditions [STCs], the Planning Protocol, Funding and Mechanics Protocol. Toolkit, Performance Measurement and Standard Reporting Workbook. October
12 Hospital Industry Engagement NJ holds monthly meetings and periodic update conference calls with representatives of each of the Hospital Associations soliciting industry input. A number of well attended classroom and webinar training sessions have been critical in educating and assisting hospitals to understand the program. During the application review process there were face-to-face meetings and conference calls held with every applying hospital. There are hospital calls with a member (s) of the DSRIP team almost every day. The NJ DSRIP website has become an essential tool for DSRIP communication. October
13 Hospital Industry Engagement NJ has a 7 member Quality and Measures Committee consisting of clinical quality experts that meet regularly to discuss and review measures, and attribution NJ Learning Collaborative began meeting in June of this year and has been a resounding success with every hospital participating, and hospital representatives presenting their project implementation challenges and successes. October
14 October
15 Opportunities and Challenges Seen Thus Far Opportunities DSRIP is among the initial pay for achievement programs nationally-a departure from Fee-for-Service payment systems. Focus is on the low income patient population A population that has been minimally managed from a medical management standpoint compared to insured patient populations. Chronic disease projects represent high resource utilization to State Medicaid Programs. The lessons to be learned from the points listed above are a great learning opportunity for the States and hospitals that should pay future dividends. October
16 Opportunities and Challenges Seen Thus Far Challenges Time-DSRIP is labor intensive on all parties-the State, CMS, and hospitals. For example the NJ DSRIP team and CMS have spent over 2,000 hours on calls addressing program design, application review and implementation since January All parties seem to provide strong efforts, but the DSRIP program is so new every aspect of the program is designed from scratch. There is no box recipe for anything. Deadlines tend to be extended. The normal give and take in negotiations are protracted over an extended period of time. For example the attribution design took six months to negotiate. Talented team members are needed in every aspect of the program-people who have high problem solving skills. October
17 Opportunities and Challenges Seen Thus Far Challenges Implementation The DSRIP Team spent countless hours in education and coaching of hospital applications and reporting. Every DSRIP application submitted needed significant revisions. Lessons learned - spend as much time as you can to assist hospitals, providing samples of completed applications for hospitals to follow, and maybe even conducting classes for each section of the application. The NJ DSRIP program relies on quarterly and annual reporting There is a need to adhere to a schedule of activities needed to; Produce and review reports Educate hospitals on report completion Package reports for CMS review and approval Strong project management skills and deliverables are essential to meeting DSRIP time tables October
18 October
19 Emerging Policy Questions Will the landscape of the low income population change with the evolution of the Affordable Care Act? Will the low income population with insurance coverage expanding have greater access to routine care? Will the low income population become more attractive to private sector hospitals? Can the DSRIP program be the catalyst for transformational change? To what degree is population health achievable for a population that faces many more challenges than their health care? DSRIP will provide a greater level of insight on patient/recipient compliance issues. October
20 October
21 October
22 Pay for Achievement Stage 1 & 2 October
23 Pay for Achievement Stage 3 Pay for Performance - Project- specific Stage 3 Project Quality Improvement - Hospital minimizes gap between its baseline and improvement target goal by ten percent for each of the 4 11 project measures. Line 1 Improvement Target Goal (90th percentile) Line 2 Baseline Line 3 Gap = Improvement Target Goal Baseline [Line 1 Line 2] ( ) Line 4 Required reduction in the gap (10%) 0.10 Line 5 Line 6 Line 7 Required reduction = Gap * 10% [Line 3 * Line 4] Expected Improvement Target [Line 2 + Line 5] Actual Performance Result 2.75 (27.50 * 0.10) ( ) ü Payment awarded October
24 Pay for Achievement Stage 4 October
25 October
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