[NYAPRS Enews] PNY: Community-Based Groups Have Uncertain Role In Medicaid Reform

[Harvey Rosenthal]

NYAPRS Note: The following piece underscores the critical challenges that community behavioral health recovery services face in the current NYS healthcare reform environment. We must be able to form meaningful partnerships with PPS leads, FQHCs, health plans and larger providers while transitioning to a more complex, risk-based system of service delivery and reimbursement. This will take an extraordinary and sustained effort on all of our parts.
NYAPRS is working to advance our shared concerns by setting up partnerships with the aforementioned groups, offering targeted TA and by advocating with state government and via our participation on various MRT related workgroups, most notably the state's Value Based Payment groups, on which serve the following:

*         VBP Steering Committee: Harvey

*         Technical Design I (benchmarking standards, beneficiary attribution, shared savings designs, stop loss mechanisms and setting minimum numbers of beneficiaries to enter into VBP contracts): Dick Jaros, Briana Gilmore

*         Technical Design II (what services should remain in Fee for Service, the provision of TA to challenged providers, exclusion criteria for VBP initiative, possible special status for financially challenged providers and quality and outcome measures): Alison Carroll, Briana Gilmore

*         Regulatory Impact (anti-trust laws and regulations, provider risk sharing, default risk reserves, and provider incentives, prompt payment regulations, model contract changes, MCO reporting, de-regulations and administrative reduction  & corporate practice of medicine, fraud waste and abuse, HIPAA, network adequacy, contract approval process, dispute resolution and civil monetary penalties): Edye Schwartz, Michael Stoltz

*         Social Determinants of Health (methods for measuring social determinants of health categories, how to evaluate progress with SDH, define and recommend outcomes for each SDH category, look at methods of incentivizing health activation, special focus on housing determinants and action plan, methods to capture savings, identification of and training needs of CBOs): Steve Coe, Lenora Reid-Rose, Maura Kelley, Ray Schwartz, Briana Gilmore, Harvey

*         Advocacy and Empowerment (incentives for improved health self-management by beneficiaries and making recommendations as to how the state, plans and providers should make them available, determining what falls into beneficiary 'right to know' and identifying the best method and strategy for communicating incentives and VBP relevant information to beneficiaries); Harvey (co-chair), Steve Miccio, Amy Colesante
We have contracted with Health Management Associates to support these efforts and will be sending regular progress reports to our members.

Community-Based Groups Have Uncertain Role In Medicaid Reform
By Dan Goldberg Politico New York  September 28, 2015

Hudson River Health Care is one of the largest health care providers outside New York City. It has 29 health centers across 10 counties, and sees 135,000 patients in a given year. Given the number of patients it sees, one would expect HRHCare to play an integral role in the state's plans to reform the Medicaid program.

In fact, its role will vary, and will depend on its partners.

HRHCare is a member of three Performing Provider Systems, the groups charged with implementing the programs that will, if successful, reduce avoidable hospitalizations by 25 percent in the state over the next five years. The role HRHCare is allowed to play within each of those three systems will differ based on the preference of the lead entity for each PPS. The lead entities will decide how to spend the more than $7 billion that New York and the federal government have devoted to these projects.

And because each PPS is made up of hundreds of different partners, a provider like HRHCare, a Federally Qualified Health Center, may be the top choice for a project in one PPS while playing second fiddle in another.

That means HRHCare and the thousands of other so-called downstream providers that state health officials insist are integral to the success of the program are at the whim of several masters.

In that way, HRHCare, with its 225 primary care providers, is emblematic of a much larger problem facing the state's Delivery System Reform Incentive Payment program, known as DSRIP.

Thousands of providers and community-based organizations (CBO) of varying size and strength are vying for a finite pot of money, a struggle bound to cause lots of internal battles among the very groups needed to make the state's ambitious reform a success.

"I think over the next six months to a year, precisely these tensions are going to surface," said Arthur Gianelli, president of Mount Sinai's PPS.

Mount Sinai, he said, acknowledges this is going to be a challenge and has developed a committee to maintain engagement with downstream providers.

Policy experts - both those involved with DSRIP and those watching from the outside - expect the tension to be most acute between the state's large hospitals and health systems, which pride themselves on managing population health on large scales, and the smaller providers that are more interwoven into the community.

These battles can only be avoided if DSRIP is seen not as a reform of the delivery system, its name notwithstanding, but as a bridge loan that allows providers to recoup investments long after the five-year reform program has ended.

DSRIP is structured so that all the money - billions of dollars - flows through the PPS lead entities, allowing them enormous influence over how to prioritize their work and accomplish the dozen or so projects that state health officials say are needed to transform Medicaid.

And those 25 PPS leads each see health care delivery - its needs and its faults - very differently.

Some will be more inclined to lean on a provider like HRHCare than others.

"Clearly, not being a PPS ourselves places us in a position of being on the receiving end of what each PPS is going to do with primary care," said Anne Kauffman Nolon, president and CEO of HRHCare. "We're screaming so loud for their attention because we are good at what we do."

The challenge for PPS leads is sorting all this out. HRHCare, which has been around for 40 years, is well respected in its community, but everyone is screaming for attention, and every organization believes it is good at what it does.

"At the end of the day it is really the PPS [lead's] choice," said Jason Helgerson, the state's Medicaid director, who is overseeing Medicaid reform. "Yeah, they submitted things in their application and we're going to monitor that. They made some commitment around CBO interaction so we're going to hold them to that but I think that the PPS have some discretion here. We're certainly going to keep the pressure on to maximize the use where appropriate of CBOs."

Advocate Community Partners (ACP), with more than 500 partners in its PPS, may prove to be the most interesting test case. The group's PPS lead is AW Medical, a Bronx-based physician group. Being physician led, the group has a different view on primary care providers and community-based organizations than hospitals tend to have. But the group's size - it is one of the largest PPS in the state - could lead to a bloated bureaucracy that makes managing so many partners difficult.

Henry Chen, president of ACP's board of directors, says he can overcome that obstacle by relying on his individual doctors to continue the relationships they already have, and that gives him an advantage over a hospital-led PPS when it comes to managing these relationships.

"A hospital will tend to have good relationships with CBOs, but it's likely to be much less personal and less of a face-to-face interaction or experience," he said. "The way ACP is structured -- led by physicians, not a hospital -- means we are free to take the lead ourselves in terms of formulating relationships with CBOs and using our expertise to strengthen the neighborhood and community safety net, without following the lead of a major hospital."

Chen pointed to the Association of Chinese American Physicians (ACAP), which has organized biannual health fairs in the Chinese community for the past 10 years.

Refuah, the state's smallest PPS, is the only other PPS not led by a hospital. Refuah, a Federally Qualified Health Center operating in Rockland, Sullivan, Orange and Ulster Counties, began in the early 1990s and sees some 100,000 patients each year.

That's about 30 percent fewer than its "downstream" partner HRHCare, though the two providers only overlap in Rockland.

Given that Refuah and HRHCare are both FQHCs, it makes sense they'd get along.

"Refuah considers us a full-fledged active partner," Nolon said.

That type of synergy isn't always taking place, said Judy Wessler, who sits on a DSRIP oversight panel and has been critical of some large health systems receiving DSRIP funds even though they treat only a handful of Medicaid patients.

"Forget equal partners," Wessler said. "Just even [being] brought in as partners is something that apparently is not happening."

DSRIP proponents point out that it is too soon to know for certain how community-based organizations and other downstream providers will fare. Contracts are just now being negotiated.

CBOs and physician groups have always grumbled about being pushed around or ignored by large health systems. The difference now is that the state's Medicaid waiver has made these entities interdependent in a way never before seen.

The $7.3 billion in DSRIP funding is not awarded unless the goal of reducing avoidable hospitalizations by 25 percent is achieved. And that goal can't be achieved unless everyone is working together, Helgerson says.

The challenge is that smaller provider groups and community- based organizations will likely need to invest cash and other resources up front to change how they deliver care or integrate with several PPS, and then take it on faith that they'll receive the money back when the DSRIP funds start flowing.

That's money most don't have, so they'll want to be assured they are well compensated for that financial risk.

But $7.3 billion - spread out over five years and among 25 PPS - isn't enough money to do that, which almost certainly guarantees fights between the downstream providers, who will want to be paid for their efforts, and the PPS leads, who have only so much to give and are used to economies of scale that make projects less costly for them than for the smaller providers.

Large health systems such as Sinai or Montefiore have a track record of managing population health, and much of what DSRIP aims to do these big systems have already begun to implement on their own.

They have a tendency to believe they can handle many of these projects, or already have an idea of how many of them should be accomplished. It will take discipline, Helgerson said, for them to allow a space for new ideas from community-based organizations, which are far smaller, but also much closer to the people on the ground whose health everyone is trying to manage.

"What each PPS and the lead has to decide is what can it do, what are its core competencies versus where are there others in the network who have better chance of success," Helgerson said. "I think there are community-based organizations who are more culturally competent and have greater connections to the community who are serving these individuals today and it would be cheaper and easier to leverage those organizations to become part and parcel of their service. ... What we keep encouraging is if you've got an organization out there that is credible, that does this, that's culturally competent, that is in the community already, use them first so that's why we're pressing the use of CBOs."

But there is a catch.

"That also means CBOs are now going to be accountable in ways they are not used to," Helgerson said. "They are going to have payments linked to performance metrics."

If they fail to meet those metrics, they won't get paid.

That can be quite a risk for some small providers who won't want to get saddled with too little money to accomplish too big a goal.

Gianelli says all providers need to know from the beginning that their investments in time, technology and new population health strategies aren't likely to be recouped for several years.

"The DSRIP money is going to support these investments but not underwrite them," Gianelli said.

DSRIP, he said, should not be thought of as the end goal. The five-year program is merely a bridge, according to Gianelli, to a system that relies more heavily on value-based contracts. This is where the downstream providers, and the health systems, can realize their dividends.

Hospitals and other providers will earn money with these contracts if they keep people out of the hospital, and are more effective at managing population health.

Helgerson wants between 80 and 90 percent of Medicaid payment to flow through a value-based arrangement by the end of the five-year period.

That's what DSRIP is all about, Gianelli said.

"All of us may not make as much money as we'd like through DSRIP but we are making investments that are enduring," Gianelli said. "We are laying the foundation for value-based purchasing."

http://www.capitalnewyork.com/article/albany/2015/09/8577329/community-based-groups-have-uncertain-role-medicaid-reform
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