Business Case
Comprehensive healthcare reform must be built on a wide-ranging system of performance measurement. Under the DSRIP program, the state’s 25 Performing Provider Systems (PPS) can earn Pay for Reporting and Pay for Performance Incentives, as they report improvements against metrics that are tied to National Quality Forum (NQF) standards. In DSRIP, the evidence-based quality measures are reported for two performance domains:
26 measures tied to standard industry stewards (i.e.: AHRQ; 3M; CAHPS; HEDIS) focus on potentially avoidable (re)admissions, emergency department visits and other potentially avoidable complications, as well as patient experiences.
More than 50 measures tied to standard industry stewards (AHRQ, CAHPS, HEDIS, QARR, 3M) focus on specific clinical improvement projects and associated outcome measures.
In order to transition 80% of the state’s Medicaid managed care business to value-based payment arrangements by 2020, New York also required an array of incremental data and analytic capabilities that would facilitate transparency, negotiations and critical insights among Managed Care Organizations (MCOs) and Value-Based Contractors.
Among these foundational capabilities is the ability to establish Target Budgets that incentivize the provision of efficient health care with high quality outcomes. Target budgets use historical trending with the ranking of current population and episodic costs to create prospective cost, quality and efficiency targets. This prospective method of virtual budgeting is based upon:
3 Year Weighted Baselines – The historical claims of VBP Contractors are aggregated to create a baseline that is weighted in a manner that places greater emphasis on more recent time intervals, following which, growth trends and risk adjustments are accounted for.
Target Budget Performance Adjustments – Performance adjustments use efficiency and quality of VBP contractors in the most recent years to determine financial rewards or penalties for the delivery of health care. Efficiency grades contractors based on their relative cost while quality grades contractors based on their volume of potentially preventable, poor outcomes.
The Solution
CMA designed, developed and maintains New York’s Medicaid Data Warehouse and the Medicaid Analytics Performance Portal which serve as the system of record for more than 20 years of claims and encounter data, encompassing more than 25 million lives.
The CMA team enhances this data with an array of algorithms that facilitates DSRIP as well as future VBP measurements, reports, file extracts, and ad-hoc analyses required by the state and its stakeholders. In doing so, we have enabled PPS’, MCOs and Value Based Contractors to access key quality measures, monitor trends, and explore some of the common drivers of better or poorer performance.
Among our key deliverables are:
- Claims data management and enhancement;
- Attribution algorithms;
- Recurring DSRIP Performance – Metric Calculations reflecting adjudicated claims performance tracking, benchmarking, gap to goal, costs of care for avoidable complications, total populations, subpopulations and episodes of care;
- Integration of algorithms supporting the foundational requirements of the state’s Value Based Payment initiative, including clinical risk and episodic grouping, proxy/real pricing, and the calculation of Targeted Budgets.
- Dashboards and reporting
The Results
Savings generated by the Medicaid Redesign Team (MRT) based reforms have led to an $8 billion reinvestment of federal money for New York’s DSRIP program. The Citizens Budget Commission (CBC) recently commended the MRT for transforming New York State Medicaid and establishing a blue print for reform, nationally. CBC’s Public Service Innovation Award recognizes and promotes successful innovations in the delivery of public services.
CMA is proud of its role, managing, enhancing and transforming data into insights that have enabled transparency, trust, collaboration and results among the many MRT stakeholders.