Medicaid Redesign and East Harlem: Perspectives and Analysis of DSRIP

April 27, 2017

Zina Huxley-Reicher, James BlumHuman Rights and Social Justice (HRSJ) Program, Mount Sinai

East Harlem Community Health Committee, Inc. “El Barrio Lives” by the Look Out Crewhttp://www.visitelbarrio.com/arts-culture/public-art-murals/

Principles and Partners:• Community Based: Center our work on the residents and community of

East Harlem.

• East Harlem Community Health Committee (EHCHC): Founded in 1976, the EHCHC brings together various community organizations to fight for

improved health for East Harlem.

“The Spirit of East Harlem” by Hank Prussinghttp://newyork.cbslocal.com/guide/pop-up-new-york-east-harlem-for-less-than-30/the-spirit-of-east-harlem/

What is DSRIP?

“An Overview of Delivery System Reform Incentive Payment (DSRIP) Waivers: http://kff.org/report-section/an-overview-of-delivery-system-reform-incentive-payment-waivers-issue-brief/

● Top Line: New York State, five years, $8 billion, approved in 2014.

● Goal: Foster collaboration between hospital networks and community organizations to better coordinate patient care.

● Structure: Create 25 Performing Provider Systems (PPSs) centered on hospitals incorporating a wide range of partners with Medicaid lives attributed.

● Metric: Reduce avoidable hospitalizations by at least 25 percent in five years.

“Implementing New York's DSRIP Program: Implications for Medicaid Payment and Delivery System Reform,” The Commonwealth Fund. Source: New York State Department of Health http://www.commonwealthfund.org/publications/fund-reports/2016/apr/new-york-dsrip-medicaid

(Delivery System Reform Incentive Payment Program)

Where We Started:● Commonwealth Fund and Kaiser Foundation both broadly examined

DSRIP.

● Alec Feuerbach, MS2, spent last summer investigating the early impacts of DSRIP on East Harlem and found:

○ Lack of transparency.○ Community organizations felt their voices and perspectives

were not being valued.○ Little trust between hospitals and the community.

● EHCHC wanted to be informed of DSRIP’s impact on the community.

● Sources of Information:○ State Data○ Qualitative Interviews○ Organizational Data

Digging Deeper:

● Quantitatively analyze the financial impact that participation in DSRIP has had on community organizations and qualitatively examine the impact that participation has had on the care provided to East Harlem patients.

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Mount Sinai PPS Disbursements:

● 66.4 percent of funds distributed to the PPS project management office (PMO).

● Much of the funding distributed to “Clinics” or “All Others” ended up with hospitals.

● Only 0.98 percent distributed to community based organizations (CBOs) compared to 2.3 percent statewide average.

New York City Department of Health, Mount Sinai PPS, LLC, DSRIP Year 2, Third Quarter Reporthttps://www.health.ny.gov/health_care/medicaid/redesign/dsrip/quarterly_rpts/year2/q3docs/mtsinai.pdf

One City Health PPS Disbursements:

New York City Department of Health, Health and Hospitals PPS, LLC, DSRIP Year 2, Third Quarter Reporthttps://www.health.ny.gov/health_care/medicaid/redesign/dsrip/quarterly_rpts/year2/q3docs/nychhc.pdf

● 67.7 percent of funds distributed to the PPS project management office (PMO).

● Much of the funding distributed to “Clinics” or “All Others” ended up with hospitals.

● Only 0.89 percent distributed to community based organizations (CBOs) compared to 2.3 percent statewide average.

• “I’m certain that doesn’t cover our true costs and the overtime time that we’ve put in.”

• “I think the harmful [effect of DSRIP] is the time it’s taken me away from here … in the first two years it approached 50 percent of my time. My office looks like this because of DSRIP some days.”

Trends● Funding was not disbursed quickly or equitably.

● Burdensome process and paperwork.

● Upfront and capital costs.

New York State Department of Health, DSRIP Funds Flow Guidance & NewCo FAQhttps://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/ff_webinar.pdf

Time and Money Investments:

• “I’m telling everyone no: don’t use my name, don’t add me to your list, it needs to be a true partnership.”

• “They have certainly not taken the opportunity to avail themselves of programs in the community that would have an impact on their patients.”

Trends● Surface-level outreach from the PPSs.

● Focus on ‘checking boxes.’

● Giving lip service to partnership.

New York State Department of Health, New York State Notice of Important Documenthttps://www.health.ny.gov/health_care/medicaid/redesign/dsrip/consumers/eng_optout_ph2.htm

Relationships and Opportunities:

It’s Not All Negative:• “It’s forced us to think about how we provide services and how we partner with other

organizations … I know that we would be more effective if we had closer contact with the healthcare system. Prior to this we were creating our own referral network.”

Trends● Forced recognition of funding reality.

● Organization by organization decision to participate.

● Concern about shifting to value-based payments.

Human Services Council, New York Nonprofits in the Aftermath of FEGShttp://www.humanservicescouncil.org/Commission/HSCCommissionReport.pdf

Case Study 1:

Funding Disbursements From Partner PPSsMount Sinai PPS One City Health PPS Total

DY1 Q1 (April 2015) $0.00 $0.00 $0.00

DY1 Q2 $0.00 $0.00 $0.00

DY1 Q3 $0.00 $0.00 $0.00

DY1 Q4 $0.00 $0.00 $0.00

DY2 Q1 (April 2016) $0.00 $0.00 $0.00

DY2 Q2 $8,645.84 $84.47 $8,730.31

DY2 Q3 $23,921.00 $2,563.00 $26,484.00

Total $32,566.84 $2,647.47 $35,214.31

Staff Time Devoted to Planning for DSRIPHours Per Week Staff Weeks Total Hours

May 2014 - May 2015 4 1 48 192

June 2015 - November 2015 3 2 24 144

December 2015 - February 2017 23 1 56 1288

March 2017 - Current 10 1 8 80

Total 136 1704

● Minimum wage in New York City will be $15 per hour.

● At this rate, the total value of the completed labor for planning only is $25,560.

● By December 2015, the organization had invested $2,352 in planning.

Moving Forward:

Lessons Learned:

• Allow for the possibility of success by centering social determinants of health

• Involve community partners from the start.

• Share funding equitably.

Next Steps:

• Continue quantitative and qualitative interviews.

• Expand interviews to include Medicaid enrollees.

• Inform stakeholders of findings.

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Acknowledgements:Advisors:

• Dr. Ann-Gel Palermo, DrPH - Mount Sinai• The Honorable Ray Cornbill, MBA - Cornbill Associates• Alec Feuerbach, Thought Leader - Mount Sinai

Community Partners:

• East Harlem Community Health Committee• Mali Trilla - Settlement Health• Anthony Feliciano - Commission on the Public’s Health System• Judy Wessler - Commission on the Public’s Health System

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Peers:

• Ivan Marquez, Lillian Jin, Aarti Rao, Sarah Zarrin, Hazel Lever - HRSJ Leaders

• Kamini Doobay, Inspiration• Human Rights and Social Justice Cohort 2016 - 2017

To Continue the Conversation:

● Zina Huxley-Reicher○ z.huxley.reicher@gmail.com

● James Blum○ jblum272@gmail.com

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