THE NEW YORK STATE DSRIP PLAN: SUMMARY OF KEY ELEMENTS

THE NEW YORK STATE DSRIP PLAN: SUMMARY OF KEY ELEMENTS As a central part of New York State s approved $8 billion Medicaid 1115 Waiver, the State will invest $6.42 billion in the Delivery System Redesign Incentive Payment (DSRIP) plan. The State has released the terms and conditions and a number of other documents that provide important detail on the DSRIP plan. (See link at the end of this document.) It is critical that all FQHCs participate and play a central role in DSRIP. DSRIP is expected to have major implications for all Medicaid providers, including FQHCs. The overarching goal of the DSRIP plan is to: Transform the health care delivery system in New York ; Reduce avoidable hospital use by 25% statewide and achieve significant improvements in other health and public health measures at both the provider systems and state levels; and Reduce Medicaid spending trend rates statewide. CMS is requiring the State to implement Medicaid managed care payment reform at the same time as DSRIP. The State s expectation is that at the end of 5 years, Performing Provider Systems will contract directly with managed care plans to meet all the health care needs of Medicaid beneficiaries and that 90% of managed care payments to providers will be based on value instead of volume. The following chart contains key information about the DSRIP plan and is organized by key areas of DSRIP. Note that it does not include all of the important details about DSRIP. Additional information and resources are listed at the end of this document. Key DSRIP Area Timeline April 1, 2014: DSRIP Year 0 began. This is the DSRIP 9-month planning period. May 15, 2014: Non-binding and non-required statements of interest from potential lead applicants due June 26, 2014: Applications for planning funds due August 6, 2014: Project design grants awarded September 29, 2014: DSRIP project plan application and application scoring guide posted to web for public comment October 1, 2014: Updated Performing Provider System partner list due for initial run of attribution logic October 15, 2014: Performing Provider System Planning Grant progress reports due

DSRIP Funding Pools Safety Net October 24, 2014: Updated Performing Provider System partner list due including employed physician NPIs October 27, 2014: State runs 2 nd round of initial attribution November 10, 2014: Non-public leads submit intent to pursue the 11 th Project November 12, 2014: Last interim partner list due for attribution (3 rd round) November 12, 2014: Feedback from DSRIP Design Grant progress reports posted to the web November 14, 2014: Updated redlined DSRIP Project Plan Application posted to the web November 14, 2014: Electronic DSRIP project plan application prototype released Mid-November: 3 rd round of initial attribution results published November 24, 2014: Performing Provider Systems to submit final network lists November 24, 2014: Scope and Speed of Application template released to Performing Provider System leads November 28, 2014: Project Plan Application Tool (with the exception of the Projects section) published December 1, 2014: (Optional) Project Plan Applications completed for DSRIP Support Team review December 8, 2014: Projects section of the Project Plan Application Tool published Mid-December 2014: Final attribution will be made available to Performing Provider Systems (No later than) December 16, 2014: Scope and Speed of Application responses due to KPMG Mid-December 2014: Capital Restructuring Financing applications due December 22, 2014: Final DSRIP Project Plan Applications due December 24, 2014: DSRIP Project Plan Application PDFs posted to the web and the public comment period begins January 26, 2015: Public comment period on Project Plan Applications ends February 2, 2015: Independent Assessor recommendations made public Mid-February, 2015: DSRIP Project Approval and Oversight Team public hearings and meetings regarding the Independent Assessor recommendations and Team makes final recommendations to the State March 1, 2015: Implementation Plans due from Performing Provider Systems Early March 2015: DSRIP Performing Provider System project awarded April 1, 2015: DSRIP project implementation will begin (DSRIP Year 1) Mid-April, 2015: First Year 1 payment made to Performing Provider Systems Performing Provider Systems (see definition below) will be able to apply for funding from one of two DSRIP pools: 1. Public Hospital 1 Transformation Fund 2. Safety Net Performance Provider System Transformation Fund Non-hospital based providers (that are not participating in a Health Home), must have at least 35% of all patient volume in their 1 Only available for the Health and Hospitals Corporation of New York City, SUNY Medical Centers, Nassau University Medical Center, Westchester County Medical Center, and Erie County Medical Center.

Provider Definition primary lines of business associated with Medicaid, uninsured, and Dual Eligible individuals. For hospitals to qualify, they must meet one of three tests: Must be a public hospitals, critical access hospital or sole community hospital; OR Must have at least 35% of outpatient business provided to Medicaid, uninsured and Dual Eligible and at least 30% of inpatient treatment provided to Medicaid, uninsured and Dual Eligible; OR Must serve at least 30% of all Medicaid, uninsured and Dual Eligible in the proposed region. The state will consider exceptions to the safety net definition on a case-by-case basis if it is deemed in the best interest of Medicaid members. Any exceptions that are considered must be approved by CMS and must be posted for public comment 30 days prior to application approval. Providers participating in Health Homes are deemed to be safety net providers for purposes of DSRIP. Non-qualifying providers may participate in Performing Providers Systems. However, no more than 5% of a project s total valuation may be paid to non-qualifying providers as a group. Performing Provider Systems Lists of eligible providers are available at the link below. Coalitions of safety net providers that are funded to participate in a DSRIP project are called Performing Provider Systems. The State will not fund a single provider. The goal of DSRIP is to have each Performing Provider System responsible for most or all Medicaid beneficiaries in the given geography or medical market area. The State expects that Performing Provider Systems will include all of the major providers of Medicaid services in their region. Performing Provider Systems must have a minimum of 5,000 attributed Medicaid beneficiaries a year in outpatient settings. Lead Applicant Patient Attribution and Performing Provider Systems Payment A list of emerging Performing Provider Systems is available at the link below. Each project must designate a lead coalition provider who will be held responsible for ensuring that the coalition meets all requirements of Performing Provider Systems, including reporting to the State and CMS. All Medicaid beneficiaries will be attributed to one and only one Performing Provider System. If there is only one Performing Provider System in a region, all Medicaid beneficiaries will be assigned to that Performing Provider System. Because of the way the attribution methodology works, if you choose to participate in more than one system in the same geography, your patients visits will not be part of the attribution. For purposes of attribution in a region with multiple Performing Provider Systems, Medicaid beneficiaries will be assigned to one

of two categories: Utilizing Members Non-Utilizing and Low-Utilizing Members Via this process, the State will attribute Utilizing Members to Performing Provider Systems based on the recipient s current utilization patterns (also known as loyalty ), assigned primary care provider as well as the geographical appropriateness of that system. This means beneficiaries will be assigned to Performing Provider Systems in their region that include the providers most responsible for their care and the greater proportion of services. The State will begin by following the two step process below. STEP 1: Assign a population subcategory based on the following four mutually exclusive populations. 1. Developmental Disabilities (OPWDD Service Eligible Code 95) 2. Long Term Care (Only NH residents) 3. Behavioral Health (SMI/Serious SUD) 4. All Other STEP 2: Apply specific attribution loyalty logic that has been specifically designed for each of the four subpopulations based on a clinically relevant hierarchy of service connectivity for each category. The State will run all visit counts through the attribution system above to match visits to a provider. After all visits against all providers are tallied up for a given service type, the methodology attributes the member to the Performing Provider System with the highest number of visits for the recipient in each service population subcategory. The State will attribute Non-Utilizing Members, Low-Utilizing Members, and the uninsured based on participation in Project 2.d.i. (a.k.a. the 11 th Project). The 11 th Project will focus on promoting the activation and engagement of Medicaid members with low/no utilization and the uninsured. If a public hospital serves a region, that public hospital Performing Provider System will have the right of first refusal to pursue the 11 th Project. If no public hospital exists in a region or the public hospital decides not to pursue the 11 th Project, the one or more non-public hospital Performing Provider Systems may pursue it. The 11 th Project must be a Performing Provider System s 11 th project selected in addition to 10 other projects. If a Performing Provider System is the only system pursuing the 11 th Project in a region, all Non-Utilizing members, Low-Utilizing members, and the uninsured will be attributed to that Performing Provider System. If multiple non-public hospital Performing Provider Systems purse the 11 th Project in one region, these populations will be attributed based on the relative percentage of Utilizing Members in the region that were attributed to each Performing Provider System. The State will then share the results of the attribution with Managed Care Plans and ask them to make necessary corrections based on more current beneficiary utilization information (e.g., recent PCP assignment or specialty service). For the first year, the State ran an initial draft Performing Provider System attribution in early October, but the results left 1.7 million members unattributed. The State is now requiring Performing Provider Systems to submit the individual NPIs for all

Project Plan Design Approved Projects to Include in Performing Provider System Plans employed physicians to address this issue. The 2 nd round of initial attribution was run October 27, 2014 and made public via the DSRIP webpage. A 3 rd round of attribution will be run on November 12, 2014 with the results to be published mid-november. The final partner lists for each Performing Provider System are due November 24, 2014, and the finalized attribution will not be made available until mid-december. Performing Provider Systems must design and implement projects that aim to: Create appropriate infrastructure and care processes based on community need, to promote efficiency of operations and support prevention and early intervention; Integrate settings through the cooperation of inpatient and outpatient, institutional and community-based providers, in coordinating and providing care for patients across the spectrum of settings in order to promote health and better outcomes, particularly for populations at risk, while managing total cost of care; and Manage population health. Each Performing Provider System will employ multiple projects to transform health care delivery and address the broad needs of the population that the system serves. These projects, described in Attachment J, are grouped into four domains; each domain includes specific strategies and projects: Domain 1: Overall Project Progress Domain 2: System Transformation Projects Domain 3: Clinical Improvement Projects Domain 4: Population-wide Projects Performing Provider Systems must implement at least 5 and no more than 10 projects (with the exception of those Performing Provider Systems pursuing the 11 th Project), including at least: 2 system transformation projects 2 clinical improvement projects 1 population-wide project. Valuation to Determine Payment Each Performing Provider System s DSRIP project plan must specify which projects it will implement and the corresponding specific set of milestones and metrics that the State lists for each domain. Each Performing Provider System should select projects based on the mandatory community needs assessment. The rationale for each project must be described in the DSRIP project plan, as described in Attachment I. Once the State receives DSRIP project plans and applications, they will use a complex valuation formula to calculate the maximum amount a Performing Provider System could be paid. As described below, there are a number of things that could change each Performing Provider System s valuation, including how good the overall application is (e.g., does what it is proposing match what the community health assessment revealed?), the number of Medicaid beneficiaries (and the uninsured if pursuing the 11 th

Workforce Transformation Payment Governance Project), how many projects a system proposes to implement, etc. Valuation will follow a five-step process: 1. The first step assigns each project in the Strategy Menu (Attachment J) a project index score, which is the ratio out of a total of 60 possible points of each project. 2. The second step creates a project per member per month (PMPM) by multiplying the project index score by the State s valuation benchmark. The valuation benchmark is pre-set by the State and varies based upon the number of projects proposed by each applicant. 3. The third step determines the plan application score for the performing provider s application based on a total of 100 points possible for each application (X/100 = Application Score). 4. In the fourth step, the maximum project value is calculated by multiplying the project PMPM, the plan application score, the number of Medicaid beneficiaries (and the uninsured if pursuing the 11 th Project). 5. Once the maximum project values have been determined, the maximum application value for a Performing Provider System is calculated by adding together each of the maximum project values for a given Performing Provider System s application. Performing Provider Systems may receive less than the maximum amount if they do not meet metrics and/or if DSRIP funding is reduced because of the State does not meet its statewide goals. Performing Provider Systems approved to implement the 11 th Project may be awarded bonus points in their Project Plan application score to reflect the extra effort needed to address the project s target populations. Each DSRIP plan must include a comprehensive workforce strategy that identifies all workforce implications, including: Employment levels Wages and benefits Distribution of skills How workers will be deployed to meet patient needs in the new delivery system Each Performing Provider System s project plan must include a funding distribution plan that specifies in advance the methodology for distributing funding to participating providers. Although the State will provide some guidance, each system has to decide how they will do this. Providers will receive DSRIP payments for reporting milestones (P4R) and/or meeting performance targets for defined metrics (P4P) for a given project during a performance period. There will not be any payment for partially meeting a performance target/milestone. The application must include a detailed description of how the Performing Provider System will be governed. Strong centralized project control is encouraged.

Data Sharing High Performance Pool Evaluation All providers that participate must commit to the project for the life of the waiver. The governance plan must also include a process by which the Performing Provider System will progressively advance into becoming an Integrated Delivery System. To help facilitate the integration, the State has proposed regulations establishing a process for entities to obtain a certificate of authority for Accountable Care Organizations (ACO) pursuant to Public Health Law Article 29-E. DSRIP Project Plan applications will include an opportunity to apply for an ACO certificate of authority. A Notice of Rulemaking for the proposed regulations appears in the October 15, 2014 State Register. Each Performing Provider System must have a data agreement in place to share and manage data on system-wide performance. Up to 10% of DSRIP funds will be set aside to fund the high performance fund. Performing Provider Systems that have achieved performance improvement beyond the stated target improvement value in their approved DSRIP project plan will be eligible for additional payment from the DSRIP high performance fund, based on the level of achievement and not to exceed 30% of their DSRIP project value. Performing Provider Systems: The State will identify an independent evaluator. Performing Provider Systems will be evaluated on performance on DSRIP milestones collectively, as a single entity. The State will require providers to provide data. A draft Project Evaluation Plan has been released which describes the methods that will be used by the independent evaluator to assess each Performing Provider System. Statewide Evaluation: The State must meet statewide performance goals or it will be subject to funding reductions. If DSRIP funding is reduced, all Performing Provider Systems funding will be reduced by an equal proportion. Managed care contracts and value-based payment The state must meet all four of the following milestones in order to avoid DSRIP reductions: 1. Statewide performance on a universal set of delivery system improvement metrics as defined in Attachment J. Metrics for delivery system reform will be determined at a statewide level. 2. Composite measure of success of projects statewide on project specific and population-wide quality metrics. 3. Growth in statewide total Medicaid spending, including MRT spending, that is at or below the target trend rate, and growth in statewide total inpatient and emergency room spending at or below the target trend rate. 4. Implementation of the State s managed care contracting plan and movement toward a goal of 90% of managed care payments to providers using value-based payment methodologies. The waiver is meant to leverage changes in the health care delivery structure to further the transition to value-based payment. Performing Provider Systems are encouraged to move away from fee-for-service payment structures within the PPS. The State will be engaged in Medicaid managed care payment reform simultaneous to DSRIP, paying for quality and a better patient care experience.

The State s vision is that at the end of 5 years, Performing Provider Systems will contract directly with managed care plans to meet all the health care needs of the Medicaid beneficiaries that are served by the system. MORE DSRIP INFORMATION: CHCANYS DSRIP webpage: http://www.chcanys.org/index.php?src=gendocs&ref=dsrip_resources&category=ny%20state%20policy New York State DSRIP Resources: All of the State s current documents and other resources about DSRIP may be found at this link: http://www.health.ny.gov/health_care/medicaid/redesign/delivery_system_reform_incentive_payment_program.htm The link includes a number of important DSRIP resources, including: Performing Provider Systems Letters of Intent received by the DOH classified into emerging and non-emerging (not meeting requirements) along with State Agency feedback Applications received for the DSRIP Project Design Grant (awards announced August 6, 2014) Redlined DSRIP Project Plan Application and Project Scoring Guide (including public comments received) DSRIP Project Plan Application Prototype completed by KPMG including the Independent Assessor s application scoring and responses DSRIP White Board Video on Project Plan Scale and Speed of Implementation DSRIP Dashboards including NYS Medicaid utilization and enrollment data (updated October 20, 2014) Draft DSRIP Measure Specification and Reporting Manual (public comments were due November 10, 2014) DSRIP Project Toolkit (updated October 10, 2014) DSRIP 2 nd Round of Attribution results (attribution run on October 27, 2014) and accompanying explanatory webinar DSRIP Community Needs Assessment Guidance and two-part webinar DSRIP Evaluation Plan draft (public comments were due July 21, 2014) How To Guide to DSRIP Governance DSRIP New Project, Attribution, and Valuation webinar recording and slides in which the State introduced the 11 th Project DSRIP FAQs (updated September 18, 2014 and now includes a section on the 11 th project, updates to the Vital Access Provider exception, and information regarding attribution and valuation) and recordings of two DSRIP Q&A Conference Calls Special Terms and Conditions with details about the DSRIP plan Program Funding and Mechanics (Attachment I) revised based on public comments DSRIP Strategies and Metrics Menu (Attachment J) revised based on public comments (now includes the 11 th Project)

Additional webinars including a two-part webinar that explains the details of the DSRIP plan; webinars focused on DSRIP project evaluation, DSRIP Accountable Care Organizations, DSRIP for physicians, DSRIP behavioral health, and the role of Health Homes in DSRIP; and a webinar providing an illustrative example of the lifecycle of a DSRIP PPS Databooks that contain provider and performance data by region including chartbooks mapping the occurrences of medically avoidable hospitalizations, clinical metrics, and links to other public health data sources State-identified lists of Safety Net Providers DSRIP Glossary The State plans to develop additional tools throughout the DSRIP process.