Discussing the $8 billion for N.Y. Medicaid reform Over 800 health care professionals gathered at the Sheraton hotel in Times Square on Wednesday morning to attend the Crains New York Business Health Summit. The event set out to break down the finer points of the $8 billion in waiver payments being issued to New York States Medicaid program over the next five years courtesy of the federal government. Although the Delivery System Reform Incentive Payment (DSRIP) takes federal savings generated by the Medicaid Redesign Team (MRT) and gives it to New York State to tighten up their reimbursement programs for Medicaid recipients, it could also mean fundamental improvements to the states health care infrastructure at large. As one may expect: optimists see an opportunity to usher in a new era of health care, while pessimists are worried about throwing money down the drain. Over the course of four hours, Crains passed the mic among insiders with dynamic perspectives on the payout. One of the most interesting portions of the event involved five experts sharing their views on the room for improvement, the potential for progress, and the necessary evil of jobs being lost along the way. All boats must rise The first of these speakers was Jason A. Helgerson, Medicaid director for the New York State department of health. He described the core objective of the DSRIP as, breaking down the silos once and for all between the various sectors of health care. Helgerson emphasized that although it starts with Medicaid, the structural innovations made- and education acquired- will inform all aspects of N.Y. health reform. The money will be divided among performing provider systems (PPS), which will essentially be networks of traditionally competitive health centers uniting to reduce redundancies among themselves. Helgerson sites three main factors in determining how funds will be allocated. First, each PPS can select up to 10 of 44 different projects. The more transformative projects will garner greater reimbursement, said Helgerson. Second, because this is really all about Medicaid, the money will go to the PPSs that are serving the highest volume of Medicaid patients. Third, it will depend on the quality of a servers application. There is a lot riding on your application score, said Helgerson, it is set in this planning year but stays with you for the five years of the waivers. This is about lasting change, said Helgerson, This is not about bringing a bunch of providers together, doing a bunch of good work for five years, and then letting everyone go back to the old way of doing business. Instead of focusing on the $8 billion, Helgerson said the real issue is addressing the $57 billion N.Y. already spends on Medicaid annually. Sticks and carrots Stephen Berger, the chairman of Odyssey Investment Partners, brought 10 years of health reform experience to the conversation. He believes that although the idea of DSRIP is commendable, the realization of its goals is hardly a sure thing. We have been talking for what seems like forever about the need to move away from a brick and mortar acute care system and create an integrated system built around primary care, said Berger, Crains has hosted lots of these events and yet here we are again. Berger believes that in order for real change to take place, there have to be not only financial incentives, but statutory power to implement it. He said that meaningful change requires a program with the right combination of sticks and carrots, or to put it another way, structure, money, and political will. Berger said although everyone agrees that change is needed, nobody wants to step forward and be, for example, the hospital that gets downsized. Institutions, he said, typically expect that kind of sacrifice to come from somewhere else. You cant just pay lip service. To succeed you have to internalize the recognition that the health care world will look very different in five or 10 years, said Berger. Even with billions of dollars on the table, change will not come easily. Change is expensive Jim Tallon, president of the United Hospital Fund of New York, has been working with Medicaid for decades. He described it as an overall successful program but says rising costs continue to create challenges. Over time, experience has informed legislators about what works and what doesnt. You dont go back to the options of cutting people, prices, or benefits, said Tallon, Thats the tradition of the Medicaid debate that a lot of states are still struggling with but we dont go back to that. Instead, Tallon said, we need to finance the long term demands of the system by improving its efficiency. Tallon equated those challenges to another challenge faced in health care. Whats the biggest cost of introducing electronic health records? Its the productivity time that is lost as people adjust to the new system. He also raised concerns regarding the chain of command as PPS groups emerge. Part of the legislation around the waivers will permit for overriding specific longstanding rules in the interest of making the health care system more efficient. Some of these rules have been in place for 30 years and, although many of them may be related to the problems that need fixing, Tallon wonders how people will determine who is in charge under those circumstances. The federal government, Tallon said, will want a lot of details about where the money is going and what kind of improvements are happening. He acknowledged the Crains Health Care Summit as a meaningful step towards figuring that out, In this room today we have doubled the number of people in the state who have some understanding of what is going on. Kevin Finnegan, political director of 1199EIU United Healthcare Workers East, addressed what perhaps many people regarded as the elephant in the room. Berger had addressed it too, although from a very different perspective: in the interest of a more efficient system, hospitals will be downsized and jobs will be lost. How does the state justify the loss of jobs and, more importantly, what will be done with those displaced workers? Finnegan acknowledged the necessity for change but emphasized the importance of not leaving workers behind; allowing them to retain their current wages and benefit structures. The federal waiver involvement in this process allows for the creation of new jobs and a more holistic approach to new jobs, said Finnegan. Nevertheless, we have concerns for the new ambulatory system and how workers will fit into it. As health care moves towards a more community based system and away from hospital based, Finnegan says we can learn from the history of home care services. Our state was forward-thinking in making home care Medicaid reimbursable, said Finnegan, but originally the providers were going to make minimum wage. He said that the low wage meant workers could not support their families and, in turn, quality of service diminished, turnover was high, and training was insufficient. Personal care worker wages eventually increased by nearly 50 percent, said Finnegan, And now workers provide better care and can have career advancement in the health care field. Finnegan stressed building on the strength and experience of the current work force. Finding meaningful ways for them to contribute to the redesigned community-based health industry, said Finnegan, must be a priority as the state moves forward. Health care, not sick care The last speaker for this portion of the Crains Health Care Summit was Kathleen Shure, senior vice president, managed care and insurance expansion for the Greater New York Hospital Association. Shure addressed the way health care should look if the DSRIP funds are utilized successfully. To me, its about focusing not just on the patient thats in front of [the physician], but the patient who is not in front of them, said Shure, Focusing on what those people need to stay healthy in the community. Hospitals will shrink, said Shure, but they will not go away completely. The goal is to reduce avoidable re-admissions by 25 percent. The actual amount of re-admissions for Medicaid populations is already 20 percent of all admissions, she said. That means a 5 percent reduction overall, so thats a real reduction. Shure echoed Finnegans concerns about making sure the workforce is stable and adequately compensated. She hopes the displaced workers will be able to transition into ambulatory settings or population health initiatives She also addressed the necessity for hospitals who previously thought of each other as competitors to work together in the interest of meaningful PPS development, but thinks there will be more than one working model for how those groups come together. Shure thinks those groups will inform essential details to the development of payment reform. In recent years, Medicare and Medicaid payment rates have eroded to the point that we think institutions without a commercial base are increasingly unsustainable, said Shure, So comprehensive payment reform will have to look at that underlying issue, and that has to be addressed at all levels of government if were going to be successful. There was an air of excitement in the Sheraton as attendees learned about DSRIP. According to Shure, that hopeful feeling is shared among the physicians who may be personally affected by the new legislation. I worked on a few waivers over the years and I do get the sense that this one is different, said Shure, In my conversations with hospitals around the city, theyre very engaged in this process; they really believe it is transformative. Although its hard to know if that belief stems from the level of funding or the overall push for health reform, Shure thinks meaningful change is happening and DSRIP can play a historic part. dotmed/news/story/24328?p_begin=0
Posted on: Sat, 04 Oct 2014 10:05:15 +0000