Delivery System Reform Incentive Payment Research Articles

Quality Assurance and Safety Culture in a Healthcare Organization

Patient care and quality management have as one of their primary focuses ensuring the safety of their patients. The four principles of biomedical ethics presented by Beauchamp and Childress are one quality management paradigm that emphasizes the importance of the patient. The Institute of Medicine's six improvement goals capture the essence of excellent medical treatment. Care, money, and health are the three pillars upon which the Institute for Healthcare Improvement's Triple Aim rests. The present review was written with the aforementioned contexts in mind, with the intention of highlighting the system's initiatives to address various efforts of enhancing quality and patient safety. We provide a reflective overview of healthcare legislation, policy, and regulation with special attention paid to the ideas of informed consent and informed refusal. This analysis also details the steps taken and regulations enforced by the administration and management to provide care that is focused on the individual patient. Finally, we discuss model policies like the Delivery System Reform Incentive Payment Program, which incorporates quality management frameworks, the Hospital-Acquired Conditions Reduction Program, which promotes patient safety, and the Hospital Readmissions Reduction Program, which aims to reduce hospital readmissions.

INTEGRATED CARE POLICY AND PRACTICE IN THE US: THE SCENARIO OF AGING IN CHINATOWN

Abstract Background Older Chinese adults, the fastest-growing population among older immigrants, experience multiple barriers to access quality physical and behavioral health care, including low English proficiency, low health literacy, and segregation between health care and social care sectors (Tsoh et al., 2016). While integrated care attempts to address these issues, there is still a lack of culturally sensitive integrated care practices to address the needs of older Chinese immigrants. Methods This article reviews the definition and history of integrated care policies in the U.S., and compares four integrated care models on the service user and community levels, including the Chronic Care Model (CCM), Program of All-Inclusive Care for the Elderly (PACE), Patient Navigation Model, and Delivery System Reform Incentive Payment (DSRIP) Program. Results Taking the community-dwelling older Chinese immigrants as the context, this article discusses factors that are essential to this group of older adults and proposes a framework to integrate social determinants of health in the development of integrated care practice with the infusion of cultural values and norms. Conclusion Integrated care for older immigrants asks for a complicated mass reconstruction of current care systems. We propose an innovative framework that fully takes advantage of CBO’s capacity in providing culturally appropriate services is proactive and preventive in nature by addressing social determinants of health directly, recognizes the role of family and community in older immigrants’ life and aging process, and provide equal attention to the older adults’ needs in health, mental health, and elderly care.

The Impact of Payment Reforms on the Safety Net: Examining Effects of the New Jersey Delivery System Reform Incentive Payment Program on Quality of Care Among Medicaid Beneficiaries.

The Medicaid Delivery System Reform Incentive Payment (DSRIP) program has been among the most widely adopted value-based payment strategies to drive improved population health management among safety net populations. Using comprehensive claims data from New Jersey and difference-in-differences modeling, the authors examine the impact of DSRIP pay-for-performance disease management programs on outcomes related to targeted chronic conditions. The authors find DSRIP reduced asthma hospitalizations and emergency department visits, pneumonia readmissions, and improved alcohol and drug treatment. Positive program-specific findings are encouraging for future DSRIP-like initiatives and demonstrate provider ability to successfully adapt to payment reforms.

Practice Transformation to Improve Cancer Screening Outcomes at an Academic Medical Center.

In 2011, Texas received federal approval of the 1115 Healthcare Transformation waiver, which went to support the Texas Delivery System Reform Incentive Payment Program (DSRIP) incentivizing the transformation of service delivery practices which included expanded coverage of preventive cancer screenings. There is limited evidence that quality improvement initiatives stemming from DSRIP improve cancer screening outcomes for the Medicaid, low-income, and uninsured (MLIU) patient population. The present the results of a quality initiative to improve breast, cervical, and colorectal cancer screening rates for MLIU patients receiving primary care at an academic medical center. The initiative included engaging multidisciplinary primary care teams, health information technology (IT), and quality departments to standardize workflows. We found significantly improved rates of cervical and colorectal cancer screening among patients eligible to receive one or more screenings. Aligning primary care, IT, and quality processes resulted in significant improvement in cancer screening.

ACO and Social Service Organization Partnerships: Payment, Challenges, and Perspectives

Summary The integration of clinical and health-related social needs is both essential and elusive. This study highlights components of the Flexible Services Program in Massachusetts, a novel demonstration project of the Delivery System Reform Incentive Payment program under a Medicaid section 1115 waiver. The program allows the state’s Medicaid ACOs to pilot evidence-based initiatives that address a member’s health-related social needs in an effort to improve health outcomes and reduce total costs of care. An examination of payment mechanisms established in the partnerships between the ACOs and the social service organizations, combined with interviews with leaders of the ACOs, reveals strengths and outstanding challenges that must be addressed. More attention is needed to vet partnerships and to develop process or outcome measures that demonstrate meaningful impact for patients related to care utilization, equity, experience, and chronic health conditions.

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care

BackgroundAn academic safety-net hospital leveraged the federally funded state Delivery System Reform Incentive Payment programme to implement a hospital-wide initiative to reduce healthcare-associated infections (HAIs) and improve sepsis care.MethodsThe study...

Abstract PO-205: The impact of DSRIP and practice transformation on cancer screening outcomes for Medicaid, low income, and uninsured patients in Texas

Abstract Background In 2011, Texas received federal approval of the 1115 Healthcare Transformation waiver, which went to support the Texas Delivery System Reform Incentive Payment Program (DSRIP) pool, incentivizing the transformation of service delivery practices to improve quality, health status, patient experience, coordination, and cost-effectiveness. To date, no research has described the impact DSRIP has had on cancer screening outcomes on the Texas Medicaid, low income, and uninsured (MLIU) patient population. Objective To describe the impact of practice transformation at an academic medical center primary care practice towards a value- based care delivery model on breast, cervical, and colorectal cancer screening for its MLIU patient population as a result of 1115 Healthcare Transformation Texas waiver. Study Design Retrospective analysis of electronic health record data from 1/1/2017 through 12/31/2018. Participants MLIU patients who received care at an academic medical center primary care practice during the study time frame and met the criteria for colorectal, cervical, and/or breast cancer screenings. Main Measures The primary outcomes for these analyses were proportions of the patient population who received or did not receive the recommended cancer screenings. Key Results After controlling for relevant confounders, we found significantly improved rates of cervical and colorectal cancer screening among Medicaid, low income, and uninsured patients. Conclusions Practice transformation, specifically integrating primary care, quality, and health information technology, resulted in higher rates of cervical and colorectal cancer screening among a high-risk vulnerable group of patients in one year. Further research should be conducted to determine if the findings are reproducible and if the return on investment equals or surpasses the cost of upfront and sustaining costs of practice transformation. Citation Format: Rebecca Jones, Amelie Ramirez, Ramon Cancino. The impact of DSRIP and practice transformation on cancer screening outcomes for Medicaid, low income, and uninsured patients in Texas [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-205.

Evaluating inpatient adverse outcomes under California's Delivery System Reform Incentive Payment Program.

The California Delivery System Reform Incentive Payment Program (DSRIP) provided incentive payments to Designated Public Hospitals (DPHs) to improve quality of care. We assessed the program's impact on reductions in sepsis mortality, central line-associated bloodstream infections (CLABSIs), venous thromboembolisms (VTEs), and hospital-acquired pressure ulcers (HAPUs). We used 2009-2014 discharge data from California hospitals. We used a pre-post study design with a comparison group. We constructed propensity scores and used them to assign inverse probability weights according to their similarity to DPH discharges. Interaction term coefficients of time trends and treatment group provided significance testing. We used Patient Safety Indicators for CLABSI, HAPU, and VTE, and constructed a sepsis mortality measure. Discharges from DPHs and non-DPHs both saw decreases in the four outcomes over the DSRIP period (2010-2014). The difference-in-difference estimator (DD) for sepsis was only significant during two time periods, comparing 2010 with 2012 (DD: -2.90 percent, 95% CI: -5.08, -0.72 percent) and 2010 with 2014 (DD: -5.74, 95% CI: -8.76 percent, -2.72 percent); the DD estimator was not significant comparing 2010 with 2012 (DD: -1.30, 95% CI: -3.18 percent, 0.58 percent) or comparing 2010 with 2013 (DD: -3.05 percent, 95% CI: -6.50 percent, 0.40 percent). For CLABSI, we did not find any meaningful differences between DPHs and non-DPHs across the four time periods. For HAPU and VTE, the only significant DD estimator compared 2014 with 2010. We did not find that DPHs participating in DSRIP outperformed non-DPHs during the DSRIP program. Our results were robust to multiple sensitivity analyses. Given multiple concurrent inpatient safety initiatives, it was challenging to assign improvements over time periods to DSRIP.

The evaluation of comprehensive medication management for chronic diseases in primary care clinics, a Texas delivery system reform incentive payment program

BackgroundThe Institute of Medicine reported that more than 1.5 million preventable adverse drug events occur annually in the United States. Comprehensive Medication Management (CMM) is the medication review process to improve clinical outcomes, enhance patient adherence, reduce drug therapy problems and reduce health care costs. University of Texas (UT) Physicians implemented a CMM program in several community-based clinics. We evaluated the effectiveness of CMM to reduce drug therapy problems and achieve medical cost savings.MethodsThis was a retrospective, observational study of CMM participants from October 2015 to September 2016. Program participants included patients aged 18 years or older who had taken more than 4 prescribed medications and were diagnosed with at least one of the following chronic diseases: hypertension, congestive heart failure, chronic obstructive pulmonary disease, asthma or diabetes. Under the CMM program, a clinical pharmacist reviewed patients’ electronic health records and created action plans to resolve identified drug problems. As part of the evaluation of the clinical process, two independent physicians conducted peer review on the recommendations issued by the pharmacist in order to establish inter-rater reliability of drug therapy problems and potential consequent medical services. The drug therapy problems were identified and classified into four categories: indication, effectiveness, safety and/or compliance. The average cost of avoided medical services was obtained based on cost extrapolations from the literature, combined with hospital discharge data. Potential medical services avoided were linked to the average cost of those services to calculate the total cost savings of the program from the payers’ perspective.ResultsBy reviewing electronic health records of 3280 patients, the pharmacist identified 301 drug therapy problems and resolved 49.8% of these problems with collaboration from the patient’s primary care physician or care team. The most commonly identified drug problems were related to potentially adverse drug reactions or inappropriate drug dosage. The CMM program resulted in potential cost savings of $1,143,015.ConclusionsThe CMM program resolved medication therapy problems among program participants and achieved significant health care cost savings.

DSRIP’s innovation and collaboration in population health management: A cross-sectional segmented time series model

Texas Medicaid Section 1115 waiver approved Delivery System Reform Incentive Payment (DSRIP) program has four categories, namely infrastructure development, program innovation and redesign, reporting of quality improvement outcomes, and population health improvement. A metric of the fourth category, preventable hospitalization rate, was analyzed for a set of eight diagnostic conditions to assess the impact of DSRIP on participating- and non-participating hospitals over two time periods, pre-DSRIP and post-DSRIP, with the help of a cross-sectional segmented time series regression model. Texas Healthcare Information Collection database was leveraged to obtain preventable hospitalization rate data. The dependent variables were preventable hospitalization rates of eight program-specified conditions and the independent variables were time, intervention, and post-implementation intervention. The overall combined preventable hospitalization rate for DSRIP hospitals was observed to decrease by 25.73%, whereas the overall combined preventable hospitalization rate for non-DSRIP hospitals was observed to increase by 37.57%. DSRIP hospitals had invested in coordinating healthcare projects and were subsequently reimbursed by the state for healthcare improvements. The implementation of DSRIP may have had the capacity to decrease preventable hospitalization rates in regions wherein its adoption may have improved the health of the population.

An Assessment of Pay for Performance Under California's Delivery System Reform Incentive Payment Program.

California was the first state to implement the Delivery System Payment Reform Incentive Payment (DSRIP) program, which focused on improving health care delivery for Medicaid beneficiaries in specific public hospitals. With an overall $6.7 billion investment, California provided financial incentives toward transforming infrastructure and care delivery, and toward achieving better outcomes. The authors sought to describe the California DSRIP program's level of investment in transforming infrastructure and care delivery, and self-reported outcomes of care. Data on the level of investment per hospital, project, and specific metrics per project were used to calculate investment per metrics and self-reported reduced mortality and morbidity for specific measures. Most financial incentives were allocated to development of infrastructure and process of care redesign. Among outcomes, allocations per reduction were lowest for prevention of central line-associated bloodstream infection prevention, hospital-acquired pressure ulcers, and sepsis mortality and highest for stroke deaths and surgical site infections. DSRIP is an important example of the mechanism used by California with the goal of promoting system change, improved outcomes, and increased accountability under the Medicaid program. The results highlight the potential level of investment that may be needed to achieve these goals in similar under-resourced safety net providers.

A3 thinking Applied: a Real World Process of Implementing An Asthma Home-Based Management Project(AMP)

Background A3 Lean Methodology/Thinking is a foundational management process and methodological structure for transforming health. Along with PDSA methodology it is a vital tool in problem solving and sustainable QI initiatives/intervention. Delivery System Reform Incentive Payment (DSRIP) is a NY State program aimed at transforming health care delivery and decreasing hospitalizations while transitioning to a more socially and community based system of care. When asked to launch a pediatric asthma management program (AMP) by DSRIP the A3 Lean Methodology was used from the outset. …

Medicaid DSRIP in New Jersey: Trade-offs between Broad Hospital Participation and Safety Net Viability.

The Delivery System Reform Incentive Payment (DSRIP) program, an increasingly utilized payment strategy to foster population health management by hospitals and outpatient providers, may sometimes generate financial and operational hardships for safety net hospitals (SNHs). The authors utilized a hospital survey and stakeholder interviews to examine impacts of the New Jersey DSRIP program, particularly focusing on its participatory structure that extended eligibility to all hospitals, and specific effects on SNHs. They found that the New Jersey DSRIP fulfilled its primary objective of conditioning receipt of Medicaid supplementary payments on quality and reporting of care by hospitals. It also provided an impetus to ongoing hospital-directed initiatives and introduced new areas of focus, including behavioral health and obesity. However, stakeholders reported that program implementation was not sensitive to specific constraints, priorities, and resource needs of SNHs. Some of the policies relating to outpatient partnerships, reporting of quality metrics, and monitoring low-income populations were perceived to have placed disproportionate burdens on SNHs. Despite appearing to meet its primary goals, the New Jersey DSRIP experience reveals a critical need to be responsive to problems faced by SNHs so as to limit their short-term transition costs and maintain financial viability for serving their patient populations.

97-LB: Point-of-Care HbA1c Testing in Redesign of Diabetes Management Program Lowered Costs and Improved Outcomes

Introduction: Empowering a low-income population of diabetic patients with onsite HbA1c testing results, coaching, and culturally appropriate diabetes self-management education materials improve outcomes and lower costs in a public health setting. Objectives: This study examines the positive outcomes of a redesign in the Diabetes Education and Care Management (DECM) program at Denton County Public Health, (DCPH) a participant in Delivery System Reform Incentive Payment (DSRIP) plan. Methods: Funding for ongoing management of diabetic patients across the U.S.A. remains an ongoing challenge. The DECM program elected to participate in the DSRIP program to secure funding to reach more diabetic patients with the goal of reducing their HbA1c and improve quality of life. Diabetic patients with an HbA1c of more than 9% met the DSRIP criteria for eligibility to DSRIP. Participants in the education program who followed the quarterly HbA1c appointment schedule were provided with diabetic medications and testing supplies to monitor glucose at no cost. Glycemic control was monitored by onsite testing of HbA1c during a quarterly visit at DCPH with the objective to lower the patients baseline HbA1c by 2.5%. Results presented reflect patient outcomes from Oct 2014 to Sept 2017. Results: Approximately 251 of the 400 patients met the DSRIP criteria of HbA1c over 9% during the selected dates. The average baseline HbA1c was 10.7% in year 3, which was lowered to 8.2% by year end. Health economic models have shown that, for a population of 500 patients, the improvement of 1.0% in the HbA1c results can lead to multiple complications episodes avoidance (e.g.,: amputation, cataract extraction, etc.) which would result in over U$ 500,000.00 in savings for the healthcare system. Conclusions: Our study suggests that empowering diabetic patients with education, state of art diabetes management, and onsite testing can lower overall HbA1c results leading to the reduction of complications and heath care costs. Disclosure J.P. Gallo: None. M. Richardson: None.

Spatial dynamics of access to primary care for the medicaid population

ABSTRACTPrimary care (PC) has always been underestimated and underinvested by the United States health system. Our goal was to investigate the effect of Medicaid expansion and the Affordable Care Act (ACA) provisions on PC access in Broome County, NY, a county that includes both rural and urban areas, and can serve as a benchmark for other regions. We developed a spatial system dynamics model to capture different stages of PC access for the Medicaid population by using the health belief model constructs and simulate the effect of several hypothetical interventions on PC utilisation. The government data portals used as data sources for calibrating our model include the New York State Department of Health, the Medicaid Delivery System Reform Incentive Payment (DSRIP) dashboards, and the US census. In our unique approach, we integrated the simulation results within Geographical Information System (GIS) maps, to assess the influence of geospatial factors on PC access. Our results identify hot spot demographic areas that have poor access to PC service facilities due to transportation constraints and a shortage in PC providers. Our decision support tool informs policymakers about programmes with the strongest impact on improving access to care, considering spatial and temporal characteristics of a region.

Medicaid Innovations and the Role of Academic Health Centers.

Although they represent less than 8% of all U.S. hospitals, academic health centers (AHCs) deliver almost 40% of the inpatient care for Medicaid beneficiaries. However, because of low Medicaid reimbursement rates, AHCs have had to rely on supplemental funding sources, such as disproportionate share hospital (DSH) payments and upper payment limit (UPL) payments. Recent legislative efforts and changes to payment structures have made these sources vulnerable to severe reductions. For instance, DSH payments are scheduled to be cut by $8 billion by 2021, and UPL payments are a diminishing resource for many states because the program is based on a fee-for-service model and most states are moving to managed care.In this Invited Commentary, the authors argue that cuts to supplemental funding sources would harm AHCs. They advocate instead for restructuring traditional supplemental payments to accommodate novel reimbursement models. They cite Medicaid's Delivery System Reform Incentive Payment program as an example of work to leverage supplemental payments to transform the delivery of care for Medicaid beneficiaries. AHCs should be at the epicenter of such innovations in population health for Medicaid beneficiaries. To that end, the authors encourage AHCs to build new partnerships with community-based primary care physicians and community health centers to balance the specialty composition of their faculty providers to assume the risk for Medicaid beneficiaries and other vulnerable populations.

Supporting Transformation through Delivery System Reform Incentive Payment Programs: Lessons from New York State.

The New York Delivery System Reform Incentive Payment (DSRIP) waiver was viewed as a prototype for Medicaid and safety net redesign waivers in the Affordable Care Act (ACA) era. After the insurance expansions of the ACA were implemented, it was apparent that accountability, value, and quality improvement would be priorities in future waivers in many states. Despite New York's distinct provider relationships, previous coverage expansions, and local and state politics, it is important to understand the key characteristics of the waiver so that other states can learn how to better incorporate value-based arrangements into future waivers or attempts to limit spending under proposed Medicaid per-capita caps or block grants. In this article, we examine the New York DSRIP waiver by drawing on its design, early experiences, and evolution to inform recommendations for the future renewal, implementation, and expansion of redesigned or transformational Medicaid waivers.

Innovating patient care delivery: DSRIP's interrupted time series analysis paradigm

IntroductionAdoption of Medicaid Section 1115 waiver is one of the many ways of innovating healthcare delivery system. The Delivery System Reform Incentive Payment (DSRIP) pool, one of the two funding pools of the waiver has four categories viz. infrastructure development, program innovation and redesign, quality improvement reporting and lastly, bringing about population health improvement. BackgroundA metric of the fourth category, preventable hospitalization (PH) rate was analyzed in the context of eight conditions for two time periods, pre-reporting years (2010–2012) and post-reporting years (2013–2015) for two hospital cohorts, DSRIP participating and non-participating hospitals. The study explains how DSRIP impacted Preventable Hospitalization (PH) rates of eight conditions for both hospital cohorts within two time periods. MethodsEight PH rates were regressed as the dependent variable with time, intervention and post-DSRIP Intervention as independent variables. PH rates of eight conditions were then consolidated into one rate for regressing with the above independent variables to evaluate overall impact of DSRIP. An interrupted time series regression was performed after accounting for auto-correlation, stationarity and seasonality in the dataset. ResultsIn the individual regression model, PH rates showed statistically significant coefficients for seven out of eight conditions in DSRIP participating hospitals. In the combined regression model, the coefficient of the PH rate showed a statistically significant decrease with negative p-values for regression coefficients in DSRIP participating hospitals compared to positive/increased p-values for regression coefficients in DSRIP non-participating hospitals. Conclusion and implicationsSeveral macro- and micro-level factors may have likely contributed DSRIP hospitals outperforming DSRIP non-participating hospitals. Healthcare organization/provider collaboration, support from healthcare professionals, DSRIP's design, state reimbursement and coordination in care delivery methods may have led to likely success of DSRIP. Level of evidenceIV, a retrospective cohort study based on longitudinal data.

Delivery system innovation and collaboration: A case study on influencers of preventable hospitalizations

ABSTRACT The fiscal pool that funds Delivery System Reform Incentive Payment (DSRIP) projects has four interlinking categories, Categories I – IV. DSRIP that was adopted in nine counties of southeast Texas detected a decrease in Preventable Hospitalization (PH) rates formulating the problem statement: What were the proposed factors that influenced the detected decrease? The article is a delineation of the presumable influencers within DSRIP that may have resulted in decrease in PH rates, those likely being physician-hospital collaboration, mechanisms of reimbursements, types of measures leveraged to report quality initiatives and interplaying healthcare externalities within the implemeted counties. The paper explains functioning of the four aforementioned influencers, examines how those may have impacted DSRIP and thereafter elucidates mechanisms these influencers in a detailed discussion. Physician-hospital collaboration propagated relationship centered care geared towards patients. State reimbursements provided a fiscal ballast to initiate and continue DSRIP activities. DSRIP’s Categories itself were designed in a systematic way so as to procure health outcomes in a continual process. And lastly, interplaying healthcare externalities such as the presence of Medicaid Managed Care/Health Maintanence Organizations may have impacted patient health in the implemented areas. At large, DSRIP may have exemplified coordination of physicians, administrators and the state so as to likely procure outcomes in healthcare quality as described herewith.

The Texas DSRIP program: An exploratory evaluation of its alignment with quality assessment models in healthcare

ABSTRACTProviding quality healthcare is one of the topmost priorities in the care delivery system. Quality is recognized as value added to the healthcare system. Healthcare policies and programs are innovated and designed to reform delivery of patient care, an example is the Delivery System Reform Incentive Payment (DSRIP) program. In this paper, we leverage three assessment models in healthcare quality namely, Donabedian’s model, the Institute of Medicine’s Patient Care Aim model and the Institute of Healthcare Improvement’s Triple Aim model. The paper shows how DSRIP likely interrelates with and is congruent to the aforementioned assessment models. DSRIP’s goals are likely designed in such a way that they supposedly intertwine with the goals of these models. The article aims at showing how DSRIP is attempting to operationalize its own goals with those of the above models. Nonetheless, the article explains DSRIP’s inner workings and conclusively analyzes how its systemic design aligns with and conforms to these models. Lastly, the paper explains DSRIP’s logistics, project cohorts and categories, outcome reporting techniques and state reimbursement methods as parts of its systemic design so as to prospectively assist/serve policymakers and analysts whilst designing new policies for procuring outcomes in quality and health in future.