Blueprint for Change: DSRIP’s Independent Evaluator Finds Program a Success, Goals Reached
Written by the HSG Team
On December 28, New York’s Medicaid program released the final evaluation by an independent evaluator of the state’s Delivery System Reform Incentive Payment (DSRIP) program–a multi-billion investment authorized through the state’s 1115 waiver from 2014 to 2020.
The evaluation concludes that “New York’s DSRIP program succeeded in demonstrating progress towards both the MRT and DSRIP program stated goals and laid the foundation and pathways for successful and promising practices to continue.”
The HSG team dove into the details to provide key highlights from the evaluation:
Top 10 Key Findings in DSRIP’s Final Evaluation:
1. Avoidable hospital use was significantly reduced. This isn’t a new finding, but the most important measures for the DSRIP program were related to keeping people out of the hospital. The program did exactly that.
· Potentially Preventable Readmission (PPR) Rates were reduced by 18.1% over the DSRIP program years
· Potentially Preventable Admission (PPA) Rates were reduced by 26.1% over the DSRIP program years
2. Reducing Avoidable Emergency Department Use proved challenging. The one hospital measure that reduced only slightly was Potentially Preventable Emergency Department Visit (PPV) rate. This shows how hard it is to reduce this measure and should be a focus of the next waiver–clearly more work is needed in this area and new strategies should be tested. The evaluation also hints at a possible “cascade effect,” suggesting efforts to prevent avoidable hospital admissions could negatively impact the preventable emergency department visit rate. This suggests that more analysis and thought is needed for how best to reduce unnecessary emergency department use inside the broader hospital use ecosystem.
3. Primary care significantly improved for Medicaid members. A much underappreciated aspect of DSRIP was its focus on improving primary care. The evaluation shows that quality measures tied to patient experience with primary care improved over the life of the DSRIP program. Another key measure was the percentage of primary care practices that achieved NCQA accreditation as a Patient Centered Medical Home. Post-DSRIP, there was a 26% increase in the number of nationally certified practices, impacting the experience of Medicaid members every day.
4. Quality measures of the Medicaid program improved statewide. The program was able to show maintenance or improvement in 72% of the key statewide measures over the five-year waiver period. These include things such as measures of primary care, timely access, care transitions, potentially preventable readmissions, and system integration. This finding demonstrates that the program’s benefits went well beyond just keeping people out of the hospital–it improved the quality of care Medicaid members received.
5. Nearly all Performing Provider Systems (PPSs) achieved success. The majority of the PPSs improved on almost all measures examined in the report, with several PPSs making particularly large improvements on key measures. While there is much to unpack among the many charts and graphs included in the report, New York State and CMS should be proud of what was accomplished. These organizations were, in most cases, created from scratch and asked to perform while at the same time organizing themselves– no small accomplishment!
6. There is room for improvement in behavioral health. Overall, key behavioral measures improved but performance varied widely. Qualitative feedback reflected in the report also outlines perspectives from behavioral health providers and community partners who see the need for additional focus and investment for behavioral health. Lots to unpack, but clearly more work to do to improve behavioral health care and its integration with physical health.
7. The pass/fail approach in defining “success” of PPS performance lacked sensitivity. CMS required a 10% “gap to goal” approach to calculating incentive payments. This meant that improving by less than 10% was deemed a “failure.” The report rightly points out this structural problem which should be avoided in future waiver demonstration programs. More nuanced measurement infrastructure would allow for more understanding of performance and improvement.
8. DSRIP held Medicaid spending (per member per month) virtually flat. DSRIP was implemented during a period of huge enrollment growth driven by the Affordable Care Act. The fact that PMPM spending rose by only 1.9% over 5 years helped New York State afford the new enrollment. Also interesting is the change in the mix of services paid for under the program. There were significant reductions in hospital spending while at the same time increased spending in ambulatory care, pharmacy, and long-term care. These findings should also influence the next waiver, especially as it relates to rising costs in pharmacy and long term care, both likely to drive Medicaid spending in the future.
9. DSRIP transformed the delivery of health care in New York. PPS staff, health and social care providers, and community leaders participated in surveys and focus groups over the life of the DSRIP program as part of the evaluation. More than 70% reported that the DSRIP was extremely, very, or moderately effective. DSRIP successes observed by these respondents included stronger and more effective care collaboration, reduction of barriers between physical and behavioral health, cultural shifts to focus on population health and social determinants of health, opportunities for innovation, and investments in local infrastructure and workforce needs.
10. DSRIP is a blueprint for how to drive large-scale change. New York’s effort to leverage its Medicaid program to drive delivery system integration and improvement remains one of the most ambitious efforts of its kind ever tried in the world– yes, world! With over $8 billion invested, millions of Medicaid members, more than 80,000 providers – the raw scale of the undertaking was massive. Many thought it could not be done, but what DSRIP offers is a blueprint for how large scale change can succeed and deliver results to the ultimate stakeholder– New Yorkers accessing the health care system.
What to Do With the Findings
DSRIP has clearly been successful in incentivizing local, place-based collaboratives of health and social care providers to move population-level outcomes and accelerate the move to value-based care. These efforts have resulted in improved outcomes for Medicaid members, reshaped New York’s health care delivery system, and garnered attention from across the world.
The best next thing to do is to use this evidence to continue to build a more member-centered, integrated, high-quality, cost-efficient health system–the evidence in this evaluation about how DSRIP was successful and where DSRIP fell short should become the foundation for the state’s next 1115 waiver amendment request. Utilizing new knowledge created during DSRIP is the best way to make good on the strong foundation that has been built.
New York Medicaid officials have signaled their intent to seek a new investment from CMS. A concept paper was released in August 2020, and a formal waiver amendment submission is expected to be released in January 2021. As New York and CMS work together to develop future programs in the state, much must be learned from DSRIP and this evaluation should guide the development of the new proposal.
More on the Evaluation
The document is substantial – more than 500 pages of findings tied to the state’s original DSRIP evaluation design, and based on analysis of sources including claims and administrative data, PPS reporting and performance, interviews and focus groups with key PPS staff and partner organizations, and patient experience feedback through formal surveys.
Also, the report has been a long time coming – New York’s DSRIP program ran from April 2014 – March 2020, and the report was a key requirement tied to CMS approval of the overall investment. New York contracted with an Independent Evaluator (IE) to design & implement a robust evaluation of DSRIP. An interim evaluation report was released in August 2019, and New York submitted the draft of the final evaluation document in September 2020. CMS provided feedback, an updated version was submitted for approval in August 2021, was approved by CMS, and was released this week.
The report is a detailed resource providing a comprehensive overview of the state’s DSRIP program along with context on other key federal and state health care delivery system initiatives including the Affordable Care Act and Medicaid Redesign Team. There is a significant amount of information and detail to review and unpack. Before the report’s release, some of the key overall performance outcomes of DSRIP - such as the achievement of reductions in avoidable hospital use - had been disclosed through state presentations and public documents. Not all of the news outlined in the report is “new.”
A Quick DSRIP Recap
New York based its DSRIP program on the demonstrated success of the state’s Medicaid program in bending the cost curve after the state generated $17 billion in federal savings and improved quality outcomes through Medicaid Redesign Team (MRT) initiatives dating back to 2011. CMS approved the initial DSRIP request in April 2014 and committed $8 billion of federal investment to DSRIP and DSRIP-related programs through March 2020.
DSRIP focused on transforming the state’s health care delivery system and rewarding value over volume by reducing avoidable hospital use across the state, creating integrated delivery systems, and supporting the move toward value-based payment (VBP) arrangements.
25 Performing Provider Systems (PPS) — collaboratives of providers and community-based organizations assigned to specific regions in the state — implemented population health, clinical improvement, and system transformation projects at a local level. PPS earned performance payments for achieving and reporting specific milestones and metrics. In addition, New York committed to shift 80% of all Medicaid managed care payments to VBP arrangements by March 2020, as outlined in the state’s VBP Roadmap. The program included a planning year (Year 0) and five years of DSRIP program implementation.
What’s missing from the final DSRIP evaluation report?
Not much detail is included about New York Medicaid’s path to VBP. The move to VBP was a vital part of the DSRIP program, yet is only marginally referenced, as it was not part of the evaluation design. The results-to-date of the state’s VBP commitment are significant and a major DSRIP success story: more than 80% of all Medicaid managed care payments in New York are now value-based.
Want to share your takeaways or learn more? HSG has a team of experts in delivery system reform, Medicaid and Medicare programs, and value-based care, and we’d love to connect. Stay up to date and follow us @hsg_global or send us an email at connect@hsg.global.
