HIMSS18: What providers can learn from Medicaid delivery reform

Starting in 2010, states began implementing Delivery System Reform Incentive Payment, or DSRIP, programs aimed at changing how hospitals and other providers delivered care to Medicaid beneficiaries. New York was one of the later states to adopt the initiative but saw success in reducing preventable utilization while tackling the effects of the opioid epidemic.

Joseph Conte, PhD, has been the executive director of the Staten Island Performing Provider System (PPS) since 2015, the year New York’s DSRIP program was implemented. Having served as an administrator at other hospitals in the New York borough, including Richmond University Medical Center, Conte knew delivering care to Medicaid beneficiaries there was locked in the fee-for-service mindset of ordering more services and focusing on individual encounters, not value-based care and population health.

On top of the $6.42 billion in funding available to Conte’s and 24 other PPS groups in the state, New York’s DSRIP program had the benefit of learning best practices—and mistakes to avoid—from earlier adopters like California and Texas.

“You really do need a broad-based strategy when you’re trying to impact six million people,” Conte said. “You can’t just look at large, academic medical centers or focus on hospital-centric services. You need to include every provider.”

In his HIMSS18 presentation on March 6, he’ll emphasize that coordination and information management is crucial to making these delivery system reforms work. While the Staten Island PPS made partners of two hospitals, 17 population health practices, 13 behavioral health providers, 10 skilled nursing facilities, seven home health management agencies and other primary care and specialty providers the relationships extended beyond healthcare entities. Conte said data sharing was “critical” among partners like public schools and the New York Police Department.

Facilitating that data sharing was a challenge, Conte said, as was the shift in workflow compared to a traditional FFS model, the short-term pressures on income by emphasizing outcomes over patient volume and the integration with other providers.

“In the fee-for-service world, you see a patient for an ear ache, you treat an ear ache and off they go,” Conte said. “In this environment, you’re trying to understand how patient’s depression is being managed, if they have an alcohol problem—you’re looking more deeply into care over the course of a cycle.”

Operational headaches aside, the initiative achieved or exceeded many of its targets faster than anticipated. Conte said the PPS surpassed its goal of reducing preventable emergency room and hospital visits by 25 percent two years ahead of schedule and is nearing a 50 percent reduction in avoidable behavioral health-related ER visits.

Another “enormously successful” part of the PPS in Staten Island, Conte said, has been offering new tools to tackle opioid addiction and abuse. Just as the initiative was starting, drug overdose deaths spiked across New York City, with Staten Island having the highest death rate (31.8 per 100,000 residents) out of the five boroughs in 2016.

SI PPS has several strategies to tackle the opioid addiction problem among the Medicaid population. For example, they’ve put peer recovery coaches into emergency rooms so they can meet with patients who come into hospitals for an opioid overdose. Their combined initiatives helped drop opioid mortality in Staten Island by 25 percent in a single year, Conte said.

There’s still room for improvement for these initiatives, he added, particularly on opioid addiction. Despite all the attention healthcare providers are now paying to the epidemic, there’s still a stigma attached to addiction, Conte said, and the system is still geared to reacting to overdoses rather than more proactive approaches.

For attendees to his HIMSS presentation, Conte hoped they would see that while his project was focused on a Medicaid population in an urban area, its lessons are applicable across the healthcare system.

“Good practice affects all patients,” Conte said. “Good data management and good business intelligence that comes from that really brings a lot of strategic direction to how you can reorganize and restructure. As we move away from this fee-for-service world into a value-based purchasing environment, good data management and good partnerships are the keys to success.”