New York State’s Delivery System Reform Incentive Payment (DSRIP) program is a five-year plan to disburse a total of $8 billion in federal funding in order to comprehensively transform the way that Medicaid services are provided and paid for, with the aim of reducing avoidable hospitalizations by 25%, and converting reimbursements from volume-based to value-based payments. In order to reach these goals, the State approved 25 Performing Provider Systems (PPS), covering defined geographic regions, with each PPS including hundreds of clinics and community-based providers organized into a single contracting entity.
While the scope of DSRIP is enormous and covers all domains of healthcare, behavioral health represents a core component of system transformation because so many mental health patients have potentially avoidable psychiatric as well as medical hospitalizations. Consequently, many DSRIP projects specifically target behavioral health issues, including coordination of care between behavioral and non-behavioral providers; registries for high-need patients; integrated care, which includes three different models (behavioral care integrated into primary care, primary care integrated into behavioral care, IMPACT); behavioral crisis stabilization; and the promotion of mental health of communities. While most current DSRIP funding is tied to implementation of these projects, as DSRIP evolves, more and more funding will be tied to achievement of dozens of specific outcomes, including at least 18 different outcomes metrics which target patients with mental health or substance use disorders: 7 and 30-day follow up after mental health hospitalization; initiation of substance abuse treatment; adherence to antipsychotic medication; maintenance of antidepressant medication; diabetes screening for patients on antipsychotic medication; etc. The State has identified national benchmarks for these HEDIS measures, and PPS’s are beginning to receive payments if they make progress on the gap between their present performance and the national benchmark.
Even though DSRIP is completing its second year, significant funds are only now beginning to flow – a delay which was in part due to the complex relationships between federal and state regulators and the health plan intermediaries. Due to the delay in funds flow, project implementation has also been delayed. Regardless, since DSRIP is viewed as a bridge to value-based payments, the $8 billion in funding represents only a fraction of revenue which PPS’s will generate once they form Independent Provider Associations (IPAs) or Accountable Care Organizations (ACOs) and develop value-based or performance-based contracts with health plans.
Since DSRIP’s success depends on population health interventions, and since each PPS has hundreds of thousands of attributed Medicaid recipients, data management represents the lynchpin for achieving the program’s laudable goals. Due to confidentiality concerns and lag times for accurate claims data, the State is only now beginning to provide data to each PPS. This means that PPS’s have been flying blind until now. They have not known much about their attributed membership – who their high-utilizing patients are, how to find them – and therefore are hamstrung in trying to develop effective interventions. For example, a PPS might know that two years ago they had 50 schizophrenic patients with cardiovascular disease who required an annual cholesterol screen (one of the relevant metrics that is linked to funds), but they do not know how many such patients are currently attributed to them, and they are restricted in communicating with the providers who care for these patients. The development of patient registries will be the key to DSRIP’s success, but useful registries depend on up-to-date claims data, and it may not be until the last years of DSRIP that they are truly operational.
What does DSRIP mean for providers working in Medicaid settings? Since most mental health and substance abuse services are reimbursed by Medicaid, psychiatrists, psychologists and social workers at clinics will be significantly impacted by these reforms. Although behavioral patients represent a large fraction of the DSRIP targeted population, mental health clinics are unlikely to receive a significant portion of DSRIP funds. This is due to the fact that patients are mostly “attributed” to primary care providers. One of the early criticisms of DSRIP is that the funding is flowing through large hospital systems, and will not end up with community-based providers, including mental health or substance abuse clinics. The biggest impact on behavioral will be through investment in integrated care models, which will, and already have, increased the demand for providers with behavioral expertise.
What does DSRIP mean for behavioral health patients? We hope and expect that quality of care will improve, with better access and better care coordination. Since behavioral patients are the focus of so many DSRIP projects, insofar as DSRIP achieves its goals, there will be fewer unnecessary hospitalizations and improved follow-up, especially with medical care. All in all, considering the many behaviorally-related DSRIP projects, if DSRIP truly does achieve its goals, the Medicaid delivery system, and the mental health delivery system specifically, will be truly transformed.
Scott Wetzler, PhD is Vice Chairman and Bruce J. Schwartz, MD is Deputy Chairman in the Department of Psychiatry at Montefiore Medical Center and Albert Einstein College of Medicine.