Welcome to the Mount Sinai PPS Town Hall

April 23, 20159:30 a.m. to 10:30 a.m.

Town Hall Agenda1. Follow-up from Last Town Hall

2. Questions and Answers

3. State and PPS Updates:

1. Timeline 2. Achievement Values 3. Partner Agreement4. Value-Based Payment Roadmap

4. Questions and Answers

5. Closing

Follow-up from Last Town Hall

Ha NguyenApril 23, 2015

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Is it possible for a provider to switch from one project to another? If so, how does the provider do that? 

• Providers may switch projects by• First, advising current project leads and

consultants of their desire to switch projects. • Second, connecting with the project leads and

consultants of the new project they wish to join to ensure it is a good fit.

• Phase Two Participation Agreements will clarify partners’ roles and responsibilities in any current project(s) they are participating in.

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How does the DSRIP program define safety net versus non-safety providers? • Providers qualify as safety net providers because their

services to Medicaid and uninsured individuals represent more than 35 percent of their total volume of Medicaid reimbursable services.

• These providers are approved to be selected by the state as safety net providers upon implementation of programs that allow Medicaid reimbursement of 1915(i) services under the state plan and the 1115 demonstration.

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/safety_net_definition.htm

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How will funds flow to safety net providers versus non-safety net providers?

• Each Project Plan receives a maximum monetary valuation during application process.

• Under state regulations, providers that do not meet the DSRIP eligible safety-net provider definition may only receive, in aggregate, 5% of the performance payments from a project’s total valuation.

• The remaining 95% of the performance payment may be made to the safety-net qualified PPS providers. 

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How do I find out if my organization meets the DSRIP safety-net qualifications?A list of DSRIP eligible safety-net providers is available on the DSRIP website. If a provider sees “True” listed in the “final results” column, then the provider has passed at least one of the eligibility tests and has qualified to be a DSRIP safety-net provider.

The DSRIP safety-net list website can be viewed at: http://www.health.ny.gov/health_care/medicaid/redesign/dsrip_safety_net_definiti on.htm

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What happens to partners who want to be removed from the PPS? Can you remove partners after finalizing your partner list?

• Once PPS networks submitted for final attribution in December 1, 2014, the PPS cannot remove any partner until Year 3 (DSRIP Mid-Point Assessment) in 2017.

• PPSs may submit proposed modifications for state and CMS review, including removing PPS partners at DY3.

• These Project Plan modifications may not decrease the scope of the project unless they also propose to decrease the project’s valuation.

• Removal of a lower-performing PPS member organization requires a proposed modification and must follow the required governance procedures, including progressive sanction requirements.

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What are the DSRIP Clinical Performance Measures?

Each project has a number of Clinical Performance Measures, which will be monitored against in a Pay

for Reporting (P4R) and Pay for Performance (P4P) manner. Below are the sources of the measures:

HEDIS 2014 and 2015:

http://www.ncqa.org/Portals/0/HEDISQM/Hedis2015/List_of_HEDIS_2015_Measures.pdf

Consumer Assessment of Healthcare Providers and Systems (CAHPS): https://cahps.ahrq.gov/about-cahps/index.html

3M Health Data Dictionary

Agency for Healthcare Research and Quality (AHRQ 4.4): http://www.qualityindicators.ahrq.gov/Default.aspx

Quality Assurance Reporting Requirements (QARR) http://www.health.ny.gov/health_care/managed_care/qarrfull/qarr_2013/docs/qarr_specifications_manual_2013

Health Resources and Services Administration (HRSA)

http://www.hrsa.gov/data-statistics/index.html

The Joint Commission

http://www.jointcommission.org/performance_measurement.aspx

Other

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What are the DSRIP Clinical Performance Measures?

This document contains the clinical performance measures each project will be measured against: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/dsrip_specif_report_manual.pdf

Questions and Answers

State and PPS Updates

Art Gianelli, President Mount Sinai St. LukesApril 23, 2015

DSRIP Year 1, Quarter 1 Calendar

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State Update: Implementation Plan Submission

• PPSs will be required to submit their initial Implementation Plans for IA review by June 1, 2015

• The June 1 submission must include:• All Organizational Components including Governance,

Financial Sustainability, Cultural Competency and Health Literacy

• Initial projections for all 3 Workforce Milestones – Workforce Budget, Workforce Impact, and Workforce New Hires

• Project 2.a.i• Patient Engagement Speed for all applicable projects

• The June 1 submission WILL NOT include:• Provider Speed & Scale ramp ups (eliminated entirely)• Major risks to implementation and mitigation strategies

(included in July submission)

▶ For all projects, exclusive of Project 2.a.i, PPSs will be required to submit Implementation Plans July 31, 2015

– Provider Speed & Scale is no longer a submission requirement– Project Implementation Plan will include Major risks to implementation,

mitigation strategies, and interim steps to achieve the project requirement milestones by the required completion dates

▶ PPSs will be required to identify the network providers that will be participating in each project as part of the October quarterly reporting process (due October 31, 2015)

– There will be NO Provider Speed & Scale ramp up required

State Update: Implementation Plan Submission

Reporting and Payment Schedule

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▶ There are 4 Reporting Periods per DSRIP Year and 2 semi-annual Payment Periods per DSRIP Year (DY1 and DY2 illustrated below)– DY3 – DY5 will follow timelines like that of

DY2DSRIP Year/Quarter

Dates Covered Quarterly Report Due Payment Date

DY1, Q1 April 1, 2015 – June 30, 2015 July 31, 2015 January 2016

DY1, Q2 July 1, 2015 – September 30, 2015 October 31, 2015

DY1, Q3 October 1, 2015 – December 31, 2015 January 31, 2016 July 2016

DY1, Q4 January 1, 2016 – March 31, 2016 April 30, 2016

DY2, Q1 April 1, 2016 – June 30, 2016 July 31, 2016 January 2017

DY2, Q2 July 1, 2016 – September 30, 2016 October 31, 2016

DY2, Q3 October 1, 2016 – December 31, 2016 January 31, 2017 July 2017

DY2, Q4 January 1, 2017 – March 31, 2017 April 30, 2017

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Partner Participation Agreements

▶ Phase 1 – Broadly specifies the roles and

responsibilities of being a partner in the MS PPS network, outlining expectations of partners in areas such as data sharing, credentialing, and liability insurance.– Revised agreement distributed on 3/23

– 87% of partner agreements received

– 35 Partners remaining out of 260

▶ Phase 2 – Specifies details regarding partner

participation per project, applicable metrics and milestones, roles and responsibilities as well as funds flow related to meeting performance metrics.– Draft Agreement to be distributed by end of June 2015 for

review by PPS and Finalized by July-August, 2015.

Value Based Payment Roadmap

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What is the Value Based Payment Roadmap?

▶ Value Based Payment (VBP) Models are the mechanism by which the State plans to reinvest savings accrued through DSRIP

▶ The VBP Roadmap is a multi-year plan for comprehensive State Medicaid payment reform– New Roadmap Issued – v. 4 on April 8, 2015– Provides a menu of options that plans and

providers can choose from– Expect v. 5 sometime over the next month

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What are the options?

▶ A provider and MCO can agree to share risk for the following types of Integrated Care:– Integrated Primary Care– Care Bundles:

• Acute care bundles (ie: maternity care, stroke)• Chronic care bundles (ie: hemophilia, chronic kidney

disease)

– Total Care for a Subpopulation (ie: AIDS/HIV, DD)– Total Care for All Populations

▶ FFS payments can be used for:– Preventive and other services not conducive to VBP– Payments to downstream providers as part of Level 1

VBP arrangements

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Value Based Payment RoadmapOptions Level 0 Level 1 VBP:

Shared SavingsLevel 2 VBP:

Performance RiskLevel 3 VBP: Capitation

All care for total population

FFS with bonus and/or withhold based on quality scores

FFS with upside-only shared savings when outcome scores are sufficient

FFS with risk sharing (upside available when outcome scores are sufficient; downside is reduced when outcomes scores are high)

Global capitation (with outcome-based component)

Integrated Primary Care

FFS (plus PMPM subsidy) with bonus and/or withhold based on quality scores

FFS (plus PMPM subsidy) with upside-only shared savings based on total cost of care (savings available when outcome scores are sufficient)

FFS (plus PMPM subsidy) with risk sharing based on total cost of care (upside available when outcome scores are sufficient; downside is reduced when outcomes scores are high)

PMPM Capitated Payment for Primary Care Services (with outcome-based component)

Acute and Chronic Bundles

FFS with bonus and/or withhold based on quality scores

FFS with upside-only shared savings based on bundle of care (savings available when outcome scores are sufficient)

FFS with risk sharing based on bundle of care (upside available when outcome scores are sufficient; downside is reduced when outcomes scores are high)

Prospective Bundled Payment (with outcome-based component)

Total care for subpopulation

FFS with bonus and/or withhold based on quality scores

FFS with upside-only shared savings based on subpopulation capitation (savings available when outcome scores are sufficient)

FFS with risk sharing based on subpopulation capitation (upside available when outcome scores are sufficient; downside is reduced when outcomes scores are high)

PMPM Capitated Payment for total care for subpopulation (with outcome-based component)

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What are the VBP Goals?

▶ By DSRIP Year 5, 80-90% of Medicaid MCO payments tied to Level 1 VBP or higher– Aspirational goal of 50-70% in Level 2 VBP or

higher

▶ Adoption will be incentivized by additional MCO premium bonuses– Pass through to providers– Subject to negotiation with plans– Bonus based on type of VBP and total dollars at

risk

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Value Based Payment Timeline

▶ Aligns with DSRIP Timeline

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Provider Readiness

▶ The State recognizes that there are varying levels of provider readiness, which are:

– Leading (ready) – Learning (need time and tech. assistance) – Financially Challenged (IAAF and others that need to restructure before

VBP)

 ▶ For those who are ready, DOH has an “Innovator

Program”: – Greater incentives for early adopters that pursue high-risk VBP – Providers get up to 95% of the dollars paid by the state to the MCO – Plans not be responsible for covering losses incurred by providers

▶ Roadmap may allow limited exclusions for certain services or providers for which VBP arrangements are not applicable or appropriate. More details are forthcoming in 2015.

Questions and Answers

Closing

Art Gianelli, President Mount Sinai St. LukesApril 23, 2015