In general, DSRIP programs are designed to advance CMS’s “Triple Aim” of improving the health of the population, enhancing the experience and outcomes of the patient and reducing the per capita cost of care. There is no official federal guidance regarding what qualifies as a DSRIP program; instead states review the most recently approved DSRIP programs to understand current CMS thinking and requirements. The health care environment varies from state to state and DSRIP is designed to transform the health care environment. As a result, implementation of several key design elements varies between states to best address health care needs in the specific state. Key design elements discussed in the following sections include, eligible providers, projects and organizations, and financing.
7.3.1 Eligible Providers
The number of providers receiving DSRIP funding varies across states. For example, all acute care hospitals in New Jersey are eligible, resulting in 63 providers participating and eligible to receive funds. In California, 21 designated public hospitals in 17 hospital systems are eligible, while 7 hospitals in Massachusetts and only 2 hospitals in Kansas can participate in DSRIP programs. DSRIP waivers in Texas and New York require that funds be used for a broader set
116 The Kaiser Commission on Medicaid and the Uninsured, An Overview of Delivery System Reform Incentive Payment (DSRIP) Waivers, (October 2014).
of providers, and these states are using their DSRIP waivers to promote collaborative provider networks that consist of an anchor hospital, associated clinics, and other providers or entities. The Texas and New York DSRIP programs require providers to form partnerships and apply for DSRIP projects together. The two states differ slightly in this approach in that Texas takes a prescriptive approach by establishing 20 Regional Health Partnerships (RHPs) that interested providers may join. Each RHP is led by a public hospital or local governmental entity – such as a county or district hospital – that is responsible for funding the state match in partnership with regional health care providers. The larger provider network, however, can include community health centers, county health departments, and other non-hospital providers. New York allows the providers to establish their own partnerships based around a lead hospital, which is usually a public hospital that contributes the State’s share of funding through an IGT. With both approaches, hospitals and other providers are challenged to connect beyond their walls to foster improved patient outcomes.
Specifically for hospitals, eligibility to participate in a DSRIP program generally requires meeting standards for serving a certain proportion of Medicaid and uninsured populations. In many states, hospitals with larger Medicaid/uninsured populations are eligible to receive higher funding allocations so that transformation is targeted to these populations. This is consistent with CMS’ objective that DSRIP programs will help to transform health care for the entire population, and as such, targeting providers that serve a high number of Medicaid beneficiaries will serve to better measure the potential benefits of selected DSRIP projects. In addition, a state may require a hospital to contribute IGTs as a condition of receiving DSRIP funds, as is the case in California.
7.3.2 Projects and Organization
Each state’s pre-approved projects are meant to drive overall health system transformation consistent with the CMS triple aim. In addition, states designing DSRIP programs are required by CMS to perform data analysis to identify areas of greatest need and develop projects to meet those needs. DSRIP projects primarily fall into four categories (although the terminology differs across states): process redesign, system redesign, clinical outcome improvements, and population health focused improvements. In general, DSRIP programs are set up to focus on achieving metrics and milestones in infrastructure and system redesign (more process oriented changes) in the earlier years of the waiver and then focus shifts toward reaching clinical and population health focused metrics and milestones (more outcome based measures) in the later years of the waiver. Innovative care models that are piloted, tested, and proved successful can be replicated across the state and potentially to other states.
7.3.2.1 Process and System Redesign Projects
Process improvement projects lay the foundation for delivery system transformation through investments in tools and human resources that will strengthen the ability of providers to serve populations and continuously improve services. System redesign projects focus on fostering new and innovative models of care delivery that expand access and improve quality.
For example, process improvement projects can focus on any of the following: Developing training for the primary care workforce
Introducing telemedicine
Implementing disease management or chronic care management registries/systems Enhancing interpretation services and culturally competent care (including the
collection of accurate Race, Ethnicity and Language (REAL) data)117 Example system redesign projects include the following:
Redesigning primary care models and expanding medical homes Establishing patient navigation programs
Expanding chronic care management models and medication management programs Integrating physical and behavioral health care
Creating integrated delivery systems118
The New York DSRIP Planning Protocol is the most recent protocol that was approved, so the program offers a window into CMS’s current DSRIP strategy. Examples of New York’s systems transformation projects include:
• Create a medical village using existing hospital infrastructure
• Develop co-located primary care services in the emergency department • Create care transitions intervention for skilled nursing facility residents • Develop community-based health navigation services
7.3.2.2 Clinical Care and Population Health Improvement Projects
Clinical care improvements and population health focused improvements are tied to measurable outcomes and metrics to address patient care and safety, and improvements in overall health. Some states specify areas for clinical and population health improvement, while others allow providers flexibility to determine the key areas for improvement. Generally, over the course of a state’s DSRIP initiative, funding allocations for meeting milestones related to clinical care and population health receive higher levels of funding than process related improvements.
Example clinical care improvement metrics tracked under the California DSRIP program include the following:
Rate of sepsis detection
Effectiveness of stroke management techniques
117 The Kaiser Commission on Medicaid and the Uninsured, An Overview of Delivery System Reform Incentive Payment (DSRIP) Waivers, (October 2014).
Prevention of Central Line-Associated Bloodstream Infection (CLABSI).
In addition to these standardized requirements, each participating hospital in California must also select and report on their progress in improving outcomes for high burden conditions such as HIV/AIDS and asthma.119 Note, however, that California had the first approved DSRIP program. They are in the process of negotiating a waiver renewal that may include a redesign of their DSRIP program.
As another example, each DSRIP project in New Jersey has defined outcome measures that are similar across projects, such as:
Reduced admissions
Reduced emergency department visits Improvements in care processes Increases in patient satisfaction
Each project will have specific objectives which are primarily measured using nationally standardized metrics120. For example, specific metrics for the project to improve cardiac care by reducing 30-day readmissions requires reporting and progress on several NCQA measures, such as controlling high blood pressure and compliance with post-discharge appointments.121 In the New York DSRIP program, the clinical care and population health improvement projects include:
Clinical Improvement Projects
o Integrate primary care and behavioral health services
o Develop evidence-based strategies for disease management in high risk populations
o Expand asthma home-based self-management program
o Increase support programs for maternal and child health (including high-risk pregnancies)
• Population-wide Projects: New York’s Prevention Agenda
o Prevent Substance Abuse and other Mental Emotional Behavioral Disorders
o Increase access to high quality chronic disease preventive care and management
o Increase early access to, and retention in, HIV care
o Reduce premature births
119 The Kaiser Commission on Medicaid and the Uninsured, An Overview of Delivery System Reform Incentive Payment
(DSRIP) Waivers, (October 2014).
120 Such metrics may be those established by entities such as the National Committee for Quality Assurance (NCQA),
the American Medical Association (AMA) Primary Care Incentive Program (PCIP), the Joint Commission, the Agency for Healthcare Research and Quality (AHRQ), CMS, or the Health Resources and Services Administration (HRSA).
121 The Kaiser Commission on Medicaid and the Uninsured, An Overview of Delivery System Reform Incentive Payment
7.3.2.3 Statewide DSRIP Metrics
CMS has not released specific guidance for states regarding requirements for DSRIP programs. However, more recent waiver approvals point to certain trends such as the need for more accountability and involvement of a broader set of providers. To that point, New York has a design feature that ties total DSRIP funding for the entire state to statewide performance. In addition to the metrics and milestones applicable to each Performing Provider System (PPS) project, New York must meet statewide performance goals and targets to obtain full DSRIP funding. Failure to achieve these goals and targets will result in the withholding of some DSRIP funds beginning in year three of the demonstration. We anticipate that CMS would require some form of statewide accountability in future DSRIP programs.
7.3.3 Financing
States remain obligated to pay for their share of the cost of DSRIP initiatives under Medicaid financing requirements. As such, they must identify a source of state dollars that can be used to “match” federal funding. The majority of states with DSRIP programs use IGTs to fund the state share. A few states use general revenue to draw down federal dollars or use a combination of IGTs and general revenue. To satisfy budget neutrality requirements, some states are redirecting federal Medicaid funds that they would have spent on supplemental payments to hospitals toward new delivery system reform payments. These supplemental payments can include DSH payments or UPL payments. In the case of Florida, funds currently going into the LIP program could be made available to fund a DSRIP program if the LIP program were discontinued. However, in order to ensure IGT funding contributions are continued by the contributing entities, the DSRIP projects would likely need to be defined in ways that primarily gave access to DSRIP projects to those hospitals for which IGTs were contributed. It should be noted, however, that all financing arrangements must be approved by CMS, and a financing arrangement that directs DSRIP dollars primarily to hospitals does not appear to be in line with CMS’ desire to involve a broader range of providers in delivery system transformation. Further, approval of a financing arrangement for an existing DSRIP program in another state is no guarantee that CMS will approve similar financing approach for a new DSRIP program.
As discussed previously, one of the requirements of an 1115 demonstration waiver is budget neutrality. Specifically in the context of DSRIP waivers, it can be challenging to demonstrate budget neutrality. The cost of making payments to hospitals and other providers for broad- based delivery system reform is not an expense that the federal government would match in the absence of the waiver. As a result, states must demonstrate that their waiver will generate “savings” (i.e., a return on investment, reducing the federal cost of operating Medicaid relative to the “without waiver” cost). They can then “tap” the expected savings and repurpose them for new investments in delivery system reform.