Three key changes can help create a primary care-focused Medicaid program in New York State, PCDC said in a public comment today.
The recommendations concern the proposed amendment to the Medicaid 1115 waiver, which broadly allows state innovation within the Medicaid program.
In its comment, PCDC puts forth concepts — allocating funds directly to primary care practices, appropriately attributing patients to the providers who manage their care, and creating geographic care systems to improve population health — to achieve shared goals.
“Primary care is the foundation of the health care system and a cornerstone of healthy, thriving communities,” PCDC notes. “Without a strengthened focus on primary care in New York’s 1115 waiver amendment, we cannot make progress in managing the care, reducing cost, and improving the health of all New Yorkers.”
Read the full comment below.
Primary Care Development Corporation (PCDC) Comment on New York´s Medicaid Redesign Team 1115 Waiver Amendment Request
November 4, 2019
Thank you for the opportunity to comment on New York’s request from the Centers for Medicare and Medicaid Services (CMS) for a four (4) year Medicaid 1115 waiver amendment (“the waiver”) to further support quality improvements and cost savings through the Delivery System Reform Incentive Payment (DSRIP) program.
The Primary Care Development Corporation (PCDC) is a nonprofit organization and Community Development Financial Institution dedicated to building equity and excellence in primary care. We provide capital financing and capacity building services throughout New York State and across the country. Our mission is to create healthier and more equitable communities by building, expanding, and strengthening the national primary care infrastructure.
Since our founding in 1993, PCDC has worked with over 600 health care sites across New York, including seven DSRIP Performing Provider Systems (PPS) in all corners of the State. Nationally, we have improved primary care access by leveraging more than $1.1 billion to finance over 130 primary care projects. Our strategic community investments have built the capacity to provide 3.8 million medical visits annually, created or preserved more than 13,000 jobs in low-income communities, and transformed 1.8 million square feet of space into fully functioning primary care practices. Through our capacity building programs, PCDC has trained and coached more than 9,000 health workers to deliver superior patient-centered care. We have also assisted nearly 550 primary care practices — encompassing some 2,250 providers — to achieve PCMH recognition, impacting care for more than 5 million patients nationwide. All told, PCDC’s work has impacted 40.2 million patients in 44 states.
The purpose of a Medicaid 1115 waiver is to broadly allow state innovation within the Medicaid program. PCDC supports New York State’s efforts to transform the health care system and particularly, the Medicaid program’s use of the 1115 Waiver to strengthen community health, improve clinical outcomes, and reduce costs. The current waiver created a structure that was intended to improve outcomes through organization into PPS. These were meant to better manage the care of individuals through patient-centered medical homes, care coordination, and other primary care centered initiatives.
Despite the success over the last four years in reducing potentially preventable hospitalizations and readmissions, these newly designed entities were built around hospitals and for very specific programmatic initiatives, rather than building a robust primary care system. There was little incentive to direct funds to primary care or ambulatory behavioral health providers. Less than 10% overall of DSRIP funding went to primary care, behavioral health or community-based social service organizations, even though these organizations provide direct services to patients and have the greatest ability to provide interventions that would reduce expensive tertiary or quaternary care.
We strongly endorse the strategy that the next waiver amendment should be fundamentally focused on strengthening the primary care system to achieve the goals that we all share. The evidence is clear that a focus on primary care will lead to lower costs and better outcomes. Increasing family physician comprehensiveness of care, especially as measured by claims measures, is associated with decreasing Medicare costs and hospitalizations. And payment and practice policies that enhance primary care comprehensiveness will help “bend the cost curve.” Additionally, increased primary care physician supply is associated with improved health outcomes, including cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, and self-rated health.
Yet, estimates are that primary care – inclusive of reimbursement and value-based payments – only receives about 5-8% of total health care spending. PCDC’s research has identified significant correlations – between primary care access and overall health status; higher poverty rates and worse health outcomes; and rural counties and a lack of primary care access – based on defined measures of access and need. The State’s own Medicaid data show a decreasing utilization of primary care.
Reorganizing the NYS Medicaid payment system through another 1115 waiver would allow New York to see the benefits of a system that appropriately values and reimburses for the vital services these practitioners provide. And while it is clearly necessary to invest in our primary care workforce, we have also seen that it is simply not happening. A recent RAND study indicated that only 3% of Medicare spending is on primary care. This number is neither specific nor definitive because Medicare has no definition of primary care and does not require reporting on its spending allocation. However, whether it is 3% or 5%, it is simply drastically low compared to the potential of primary care: managing the whole health of an individual and ultimately reduce costs within the system.
Under the previous waiver, PCDC advocated for the creation of primary care plans by each PPS. While these were completed by all, they were neither actionable plans nor were they standardized to allow for tracking of activity in a meaningful way. In any new waiver, requiring a community-level primary care focus, requiring all waiver-supported entities to plan, fund, and measure primary care activities from the beginning would provide valuable information as well as a measure of the effectiveness of the primary care strategy that could be used for future reforms. Requiring reporting, specifically in a standardized form that would allow for analysis by to the State as well as independent researchers on these measures, would instill accountability into the system.
In reading the waiver amendment request, we are heartened to see the continued discussion about the importance of primary care and the understanding that often, the most appropriate care is not hospital-based. The focus on inclusion of primary care, behavioral health, and community-based organizations in any newly created or existing entities is particularly important.
PCDC urges that the New York State’s proposed waiver amendment must include three key concepts in the application to create a primary care-focused Medicaid program.
First, funds must flow directly to primary care practices. Trickle-down reimbursement rarely makes it to the target. If New York is serious about structuring the Medicaid program around primary care, waiver funding should go to primary care provider organizations either directly or through existing reimbursement channels, such as managed care organizations (MCO).
Additionally, the share of spending overall on primary care must substantially and meaningfully increase, which will, in turn, reduce the total cost of care as well as improve outcomes. Other states, such as Oregon, Delaware, and Rhode Island have already undergone such transformation efforts. Effective primary care payment supports more than just traditional primary care; it covers integrated behavioral and public health, care coordination, and related social determinants of health. This supports a shift towards team-based, community-oriented care.
There also must be sustained investment in existing incentive programs, such as the patient-centered medical home, to ensure that primary care providers can maintain their operational transformation, especially given the extensive New York State investment in this model of care.
Contracts, whether VBP, fee-for-service, incentive payments or a combination of all three, should cover not only the cost of providing direct care, but also care coordination and care management, data exchange, case-conferencing, and other population health activities. Research has shown that primary care spends a disproportionate amount of time on administrative tasks, including redundant or overlapping reporting requirements. Primary care physicians spend an average of 19.1 hours a week on reporting – nearly double that of their specialist colleagues – costing practices upward of $50,000 a year.
Second, rather than just reiterating the importance of integration of primary care and behavioral health, we should find ways to appropriately attribute patients to the providers who manage their care. This means that for many patients who have serious mental illness and primary addiction diagnoses, they should be attributed to the behavioral health organizations (BHO) where they are receiving care. These organizations would, in turn, become responsible for connecting people to primary care and for primary care outcomes through a variety of funding mechanisms, such as Certified Community Behavioral Health Clinics, that could be funded at the State level to improve primary care access and quality for this vulnerable population. Though many of these organizations may be unable to individually take risk, it is the VDE or the MCO who should support their capacity to do so over the life of the waiver (rather than assuming this will take place at the very beginning of the process.)
While substantial reporting costs and administrative burdens have affected all practices, the problem is particularly acute for organizations providing integrated care. As part of many grant projects, demonstration studies, and insurance reimbursement structures, providers are required to document and report patient- and population-level outcomes and metrics to a multiplicity of funding agencies and organizations. In New York, a health center participating in PCMH, receiving a SAMHSA PBHCI grant, seeing Medicaid-insured patients contracted with several different MCOs as part of DSRIP PPS, and engaged in Health Homes, may be required to track and report unique metrics at different frequencies via distinct systems for each program in which they participate. In a review of the practices that PCDC supported to become PCMH-recognized, the practices had an average of 16 separate contracts.
PCDC applauds the efforts that state agencies have made in recent years to consider new regulations intended to ease reporting and operational requirements for integrated and co-located facilities, including the DSRIP integrated care license. In our recent report, Closing the Behavioral Health Integration Gap: A New York Case Study (2019), we still found several barriers in the state process including limited uptake of the DSRIP integrated care license, utilization thresholds that do not meet the needs of larger health centers and practices, and service/billing limitations as well as administrative requirements that are not feasible for many health centers and providers to navigate.
The new 1115 waiver must acknowledge the multiple, and at times burdensome, reporting and operational requirements that may already exist and be required by numerous funding and regulatory bodies, and work to reduce that burden by 1) aligning metrics and 2) consider a reporting system that enables NYS Medicaid practices to report one set of metrics for all NYS Medicaid programs including to any associated VDE or MCO.
Finally, a primary-care centered Medicaid system should create and promote geographic systems of care to maximize efforts to improve population health. Overlap of patients and provider networks does not allow for appropriate population health management. Many practices PCDC has worked with over the last four years are in multiple PPS, with additional requirements from value-based contracts with insurers and have found it difficult to effect meaningful change at the population level. The Staten Island PPS has been held up as a success case; one reason is that it is the only PPS in its geography and therefore they are able to most effectively bring together all the community stakeholders, use data at the population level to inform strategic investments, and maximize resources to support transformation goals. Other states have made this decision and funnel all Medicaid programs (reimbursement, incentive payments, health homes, etc.) into one lead provider in a region with the responsibility to contract out the funding appropriately and is accountable for population health and cost outcomes.
Besides, other challenges and opportunities remain which could also be addressed in a waiver extension. The supply of primary care providers, especially in more rural areas of the state, is a continued struggle. An extension of 1115 should include strategies to ensure a sufficient pipeline of providers at all practice levels across the state. There must also be a continued focus on increasing access to capital financing for investment in facilities that appropriately support primary care and are focused on the integration of other services into the primary care setting.
Primary care is the foundation of the health care system and a cornerstone of healthy, thriving communities. Without a strengthened focus on primary care in New York’s 1115 waiver amendment, we cannot make progress in managing the care, reducing cost, and improving the health of all New Yorkers.
Primary Care Development Corporation (PCDC)
Patrick Kwan, Senior Director of Advocacy and Communications
Office: (212) 437-3927 | Email: email@example.com
Sasha Albohm, Director of Federal Affairs
Office: (212) 437-3937 | Email: firstname.lastname@example.org