1. DSRIP Financing of Medicaid: TX, NY and CA
We’ll talk about today:
History of DSRIP in California
The intersection with other value-based Initiatives in California
Where DSRIP is headed next
Core challenges and lessons learned
How health IT can help providers with core challenges today and set them up for future success.
Lisa Chan-Sawin, Consultant
Evan King, EVP, COPE Health Solutions

2. What is DSRIP?
DSRIP stands for “Delivery System Reform Incentive Payment.”
A Medicaid effort operated under a Section 1115 Medicaid waiver program that provides provider financial incentives to:
Support delivery systems changes to meet the triple aim;
Address gaps in care delivery;
Develop local care coordination & transition protocols;
Improve operations; and,
Increase care capacity and population health.
States leverage federal dollars with a match.
Budget Neutrality rules apply.
DSRIP supports California’s hospitals on cost and quality issues by asking hospitals to submit 5-year plans

3. Providing incentives for infrastructure & Outcomes
DSRIP is fundamentally an incentive payment model. FFS and managed care payments still happen. DSRIP programs:
Incentive payments for meeting relative progress measurements, growing more difficult overtime.
Some states allow partial recognition for partial achievement; others do not.
Payments in early years are generally for process measures; outcome measures in later years.
Beyond improved health outcomes, goals include:
Better IT integration
Provider integration (health & social services)
Clinical redesign
DSRIP is new work for better outcomes.
Medicaid has a long history of providing supplemental payments for volume of care.
The entire point of DSRIP is to move past notions of a federal subsidy (like DSH).
For providers to receive DSRIP payments, they must develop a detailed plan and implement a series of projects.
These projects must be new or significantly different initiatives that do not currently have a funding stream.
It can’t supplement existing programs
It can’t replace existing program funding
These projects must be detailed in a project plan that include specific metrics and milestones:
Payment is contingent in providers meeting these metrics and milestones
Requires providers to:
Identify areas for improvement from a set of allowable projects (allowing flexibility for each hospital to meet its unique needs), and
Provides incentives for achieving measurable benchmarks in those target areas.
Each target area must have its own specific measures.
Projects must use metrics that are nationally recognized measures (ex: CHART, HEDIS, NQF, etc.).
Measures can also be process measures, to show changes in that result in learning, adaption and progress.
Each hospital’s plan must include projects in each area:
Infrastructure Development – to strengthen a hospital’s ability to provide services through the use of technology, tools and human resources.
Innovation & Redesign – to support new models of care and ways to improve the patient’s experience.
Population-focused Improvement – to ensure quality of care improves through data reporting.
Urgent Improvement in Care – to improve the efficiency and performance of interventions.

4. Outcome Metrics & Avoidable Hospitalization Population Health Measures
How do dsrip payments work?
Process Metrics
Outcome Metrics & Avoidable Hospitalization $
Time
Population Health Measures
Other states have a similar financial framework minus the population health measures

5. Public & Private Providers
Comparing dsrip programs nationally CA MA TX KS NM NJ NY
Program Participants:
Public
Public & Private Providers
Hospitals Only X
Health Care Service Providers
X**
Health & Social Service Providers
Standardization:
Menu of Projects
Shared Metrics & Milestones
Some
Projects Developed for:
Individual Providers
Groups of Providers
Tie to Other State or CMS Goals:
Public Health Measures
Payment Reform
X***
Approved:
Nov
2010
Dec
2011
2012
Jul
2013
Aug 2013
Feb
2014
DSRIP States (Implemented)*
Smaller programs include:
Kansas – limited program involving 2 safety net hospitals, limited standardization of metrics and milestones
Massachusetts – limited program involving 7 public and private safety net hospitals; limited standardization of metrics or projects; a significant focus on payment reform or alternative payment strategies
New Mexico – limited to sole community providers and state teaching hospitals; protocols still in development but each provider has own set of projects
Larger programs:
California – 21 public hospitals generally in large, urban counties; limited standardization of metrics or projects
New Jersey – 63 hospitals, however hospitals “strongly” encouraged to work in partnership with other providers; highly tailored menu set of projects & metrics; providers asked to choose a public health goal that all projects had to be linked to
New York – broad program involving a large number of collaborations (40+) including social service providers, very tailored menu set, statewide goal of reducing avoidable hospitalization by 25%
Texas – broad program involving 20+ regional groups, menu of projects still broad but attempt to standardize metrics and milestones
Trends:
* Arizona’s program was never implemented. Florida and Oregon operate DSRIP-like programs, but don’t seem to be considered full DSRIP by CMS.
** New Jersey hospitals encouraged (not required) to work with downstream providers and share payments.
*** New York has a linked statewide 25% reduction in avoidable hospitalization goal that reduces all provider payments if the entire state does not reach that goal.

6. ©2015 Caradigm. Confidential.
Evolving DSRIP programs
California
Texas
New York
Program Title
Delivery System Reform Incentive Program (DSRIP)
Delivery System Reform Incentive Pool (DSRIP)
Delivery System Reform Incentive Payment (DSRIP) Program
Waiver Approved
November 2010
December 2011
February 2014
CMS Approval of DSRIP Framework
March 2011
Sept 2012
Protocols still in development
CMS Approval of Individual Plans
June 2013
Jan-Mar 2014
Duration
5 Years
5.5 Years
Federal Funding Available
$3.3B
$5.7B
$6.9B
Participating Entities
21 Public Hospitals
20 Regional Healthcare Partnerships (330 public & private providers)
20-40 Performing Provider Systems (thousands of public & private providers)
DSRIP Category Title
Infrastructure Development
Innovation and Redesign
Population-Focused Improvement
Urgent Improvement in Care
LIHP HIV Transition
Program Innovation and Redesign
Overall Project Progress
System Transformation
Clinical Improvements
Population-Wide Strategy Implementation
Project Menu Size
298 Milestones
1,322 Projects, varying milestones
44 Projects with specific milestones
Comparison of DSRIP CA, TX & NY
©2015 Caradigm. Confidential.

10. DSRIP Challenges
Showing Progress: Choosing the right metrics/populations can be challenging
Patient care and health outcome measures may take longer to achieve than anticipated
Achievability of certain metrics need to be tied to a realistic view of your population
Data, Reporting and Timelines.
Reporting timeless were a little over 60 days apart
Lack of electronic health records, and the dependence on paper record system, posed a challenge for many public hospitals (CA)
Limited data sharing capabilities made reporting and care coordination extremely difficult (NY, TX)
Workforce Capacity
Current staff took on additional DSRIP responsibilities with no/little additional resources.
As new care team models and protocols were created, organization and retraining of staff (including upstream/downstream providers) became burdensome without dedicated funding streams
17 DSRIP plans (LA County Department of Health Services includes a 4 hospital network) were approved, with all 21 DPHs participating.
The plans are diverse and cover the range of projects in the four categories
All benchmarks were met in Year 1
Lack of primary care workforce – many hospitals are having to divert from specialty and urgent care resources.
Reporting and resource issues– many hospitals are working from a paper system or have administrative challenges to contracting for reporting resources.
Comparability of data across systems – waiver offers lots of flexibility which means not all hospitals are collecting the same data.

11. Lessons learned Leadership:
Executive sponsorship critical for buy-in and alignment with strategic goals
Understand the State & CMS’s goals for DSRIP and align with them
Identify champions for each project
Create multiple communication channels to ensure everyone understand the strategic direction and moving towards the same goals
Strategic Planning:
Create dedicated clinical teams for each project
Be cautious and thoughtful in selecting goals – they should be a reach but attainable
Dedicated Attention to detail:
Create a PMO or have dedicated staff track DSRIP policy, projects and progress
Dedicate resources to IT, Workforce Retraining and Clinical Staff
Plan up front how your org & partners will share data for reporting & clinical decision making
Institute a process for rapid cycle evaluation, learning and dissemination of information

12. PRIME, DSRIP 2.0
Current 1115 Waiver expired in October 2015, but extended until December 31, New waiver agreement in concept with CMS.
Total initial federal funding in the renewal is $6.218 billion.
Possible additional federal funding in GPP to be determined after year one.
Major components include:
Global Payment Program (GPP) for services to the uninsured in designated public hospital systems (DPH). 
Delivery system transformation and alignment incentive program for DPHs and district/municipal hospitals (DMPH), known as PRIME (Public hospital Redesign and Incentives in Medi-Cal). ($3.3B over 5 years for DPHs, $466.5M over 5 years for DMPHs)
Dental transformation incentive program ($750M over 5 years)
Whole Person Care Pilot (WPC) program which would be a county-based, voluntary program to target providing more integrated care for high-risk, vulnerable populations. ($1.5B in federal funds over 5 years)
Independent assessment of access to care and network adequacy for Medi-Cal managed care beneficiaries.
Independent studies of uncompensated care and hospital financing.
The GPP converts existing DSH and Safety Net Care Pool (SNCP) uncompensated care funding – which is hospital-focused and cost-based-- to a system focused on value and improved care delivery.  The funding of the GPP will include 5 years of the DSH funding that otherwise would have been allocated to DPHs along with $236M in initial federal funding for one year of the SNCP component.  SNCP component funding for years two through five would be subject to an independent assessment of uncompensated care.  
The federal funding of PRIME for the DPHs is a total of $ billion over the five years of the Waiver, which includes $700 million for each of the first three years, $630 million in year four, and $535.5 million in year five. The federal funding for the DMPHs is a total of $466.5 million over the five years of the Waiver, which includes $100 million for each of the first three years, $90 million in year four, and $76.5 million in year five.
CMS generally has moved towards:
Narrower menu of projects with pre-approved metrics and milestones.
Collaboration with, and inclusion of, a broad range of providers, including social service providers.
Stretch goals.
DSRIP accountability bar is being set higher in each state.
DSRIP goal is statewide payment reform.
More upfront planning—with CMS planning funds.
Standardized and streamlined data reporting.
Opportunities outside of the 1115 Waiver
CMMI Innovations Grants
Accountable Communities for Health
Medicaid & Other Plan incentives

13. Thank you! Lisa Chan-Sawin, lisa@websawin.com
Evan King,