New Hampshire’s Medicaid demonstration offers another example of a state exploring a pioneering approach to value-based care. This is the latest article in a series about innovative proposals to curb costs and advance quality in state Medicaid plans.
In January 2016, New Hampshire received approval from the Centers for Medicare and Medicaid Services (CMS) to implement a Delivery System Reform Incentive Payment (DSRIP) demonstration program focused on integrating care to advance treatment for Medicaid beneficiaries with behavioral health needs. This isn’t surprising considering the “[gradual transition] to care delivery systems in which behavioral health is becoming a part of medical services.”
Under the DSRIP program, states are permitted to conduct demonstration projects to better serve their Medicaid populations without increasing costs to the federal government. New Hampshire has long suffered from a shortage of mental health professionals and has the second highest drug overdose-related death rate in the country. As a result, the state sought federal help in tackling “challenges confronting New Hampshire’s behavioral health system.”
New Hampshire’s DSRIP program led to the creation of integrated delivery networks (IDNs) across seven regions. IDNs function like traditional provider networks in that each one includes certain types of providers to meet the needs of their respective population. Each IDN includes physical health, behavioral health, and community-based social service providers and organizations.
The New Hampshire IDNs are expected to:
- Deliver integrated care based on each beneficiary’s individual needs in a holistic fashion
- Expand their region’s capacity to address behavioral health needs in the appropriate setting
- Improve care coordination during care transitions, including linking beneficiaries to community-based resources
To help meet these goals, New Hampshire requires each IDN to complete six projects to address the needs of Medicaid beneficiaries with behavioral health disorders. The six projects span three categories: statewide, core competency, and community-driven. There are two statewide projects which focus on increasing the behavioral health workforce and strengthening health information systems to support data integration. The core competency project is solely focused on integration of care but may differ based on population needs within each of the seven regions. Lastly, there are three community-driven projects which are dependent upon the results of a community health needs assessment.
IDNs will be provided payments based on performance against key milestones and quality indicators including the transition to alternative payment models (APMs). The amount of funds the IDN risks losing due to poor performance starts in year three at five percent and increases in five percent increments through year five (up to 15 percent or $4.5 million). In total, the state can receive up to $150 million in funding over the five-year demonstration period.
To promote accountability across each of the seven regions, there are both state-specific and IDN-specific metrics. For example, if one IDN is performing at a high level but another two are performing poorly, state-specific performance metrics will not be met, and payments will be withheld by CMS. The accountability metrics are all process measures for the first two years.
During the third demonstration year, which is currently ongoing, payment will also be tied to quality, access, and utilization measures. These latter measures will be the sole basis for payment during the final two years of the demonstration. The IDNs met the majority of their process measures during the first two years and one saved $1,176,022 in 2017, according to a semi-annual report. Performance measures results will be available in 2019.
The state must submit an interim evaluation report to CMS by March 31, 2019 that addresses the following research questions:
- Did the DSRIP demonstration achieve its goals of better individual care, improved population health and/or reduce costs?
- To what extent did the DSRIP demonstration improve integration and coordination of physical health, behavioral health, and transitional care between providers?
- Has the DSRIP demonstration improved the capacity of the state’s behavioral health workforce?
- To what extent has the DSRIP demonstration enhanced the state’s health information technology system to support delivery system and payment reform?
- Has the DSRIP demonstration helped IDNs become more prepared to transition to APMs?
If successful, this DSRIP demonstration stands to mark a “new direction for delivery system reform.”