NYS 1115 Waiver Concept Paper: The Highlights

Jordan Wood
by Jordan Wood

The Concept – DSRIP 3.0?

As the five-year Delivery System Reform Incentive Payment (DSRIP) program wound down its run in New York State two years ago, state officials brought together a proposal for a waiver extension – a DSRIP 2.0, if you will – that would build on DSRIP’s successes. This proposal ultimately failed to receive approval from CMS, but with COVID putting our health systems through the ringer over these last 18 months, the gaps, costs, and inefficiencies that DSRIP worked to address have only become more strained and the need to close those gaps more urgent. In light of this, New York has released a concept paper for a new 1115 waiver demonstration program that requests $17 billion to build on the work DSRIP started. New York State is setting a tone for the future of Medicaid redesign with this concept paper.

Here are a few key takeaways about what that future might look like:

A Focus on Resilience

The extraordinary pressures of the past year have highlighted just how critical a resilient healthcare system is to the wellbeing of our communities. The investments, collaboratives, and programs on offer in this concept paper represent a series of interventions meant to redesign New York’s Medicaid system for a future that is better able to withstand crises like the COVID pandemic by making equitable, whole-person care the baseline from the outset.

The concept paper suggests a few ways forward to make such a redesign be possible:

  • Accounting for all social factors alongside health factors when considering the care needs of New York State citizens;
  • Extending clinical capabilities beyond the four walls of healthcare facilities;
  • Appropriately and quickly scaling social care and health care integrations across the state;
  • Building surge capacity into the public health system.

New Organizations with New Relationships

Achieving this redesign is, clearly, a huge challenge that previous injections of federal investment have only begun to meet. Much of the concept paper is therefore devoted toward outlining two new collaborative organizations meant to drive these sweeping changes to New York’s Medicaid system. The first, Social Determinants of Health Networks (SDHNs), are regional networks that will formally organize Community Based Organizations, health systems, and healthcare providers into single, centralized points of contracting that can coordinate regional referral networks and organize key SDH interventions. SDHNs were also featured in the previous waiver extension application and remain largely unchanged from their initial formulation in that document.

Brand new for this proposal, however, is the HERO – Health Equity Regional Organizations. These “mission-based organizations” will receive planning grants under the waiver which they will use to coordinate a wide range of health systems stakeholders for the sake of enacting region-specific health equity strategies. These strategies may include needs assessments, racial justice work, housing inventory assessments, data collection and exchange, and implicit bias training. All of this planning will be for the sake of informing the continued march towards advanced Value Based Payment models throughout the New York State health system.

We’ll take a deeper dive into the structure, role, and implications of these proposed organizations in a later post, so stay tuned.

Health Equity, Digital Access, and Supportive Housing

Given the unprecedented strain healthcare providers and their communities experienced due to COVID-19, it has become clearer than ever that the future of health must include alternative pathways to care provision outside the four walls of a hospital or a clinic. The pressures of the pandemic have accelerated the rate of telehealth adoption, but these gains must be kept and made sustainable. To that end, this concept paper will create an Equitable Virtual Care Access Fund that bolsters the capacity of New York’s safety net to provide telehealth. Along with investments in telehealth, the State is also pursuing health equity in times of systemic strain through a series of interventions in supportive housing, including programs that provide employment and vocational services, behavioral health supports, accessibility modifications, and a menu of supportive housing options for HEROs and SDHNs to implement regionally.

What’s Missing and What’s Next

The August 1115 Waiver Demonstration: Conceptual Framework is just that, a framework, and is therefore lacking in many key details. There is, for instance, no information on the timeframe for application, nor on the ratio of funds flow from the requested $17 billion down through to the proposed programs and collaborations. It also remains to be seen if the current administration’s CMS leadership will be more amenable to the budget neutrality argument New York State offers to justify the requirements for an 1115 waiver than the previous administration.

Keep a eye on this space to stay in the loop as New York Medicaid redesign continues to move forward with their plans to bring lower costs, more equity, and higher quality to the state’s healthcare system.

Read the concept paper here: New York 1115 Waiver Concept Paper (FINAL) (ny.gov)