It’s a big policy development, and it’s now consuming major focus, planning and attention from state health officials and stakeholders.
The Department of Health and Executive are working to renew the state’s multi-billion-dollar 1115 Medicaid waiver in an application to federal officials at the U.S. Centers for Medicare and Medicaid Services (CMS).
To offer assistance in this effort, seven state health care associations, including HCA, have drawn up core recommendations and key amendments for consideration as part of this sprawling, multi-billion-dollar waiver being eyed for renewal.
The groups’ recommendations are presented in a comprehensive letter sent this week to the state’s Deputy Secretary for Health and Human Services Paul Francis (see here). We encourage all legislative offices to read these recommendations carefully, especially health care committee offices.
Section 1115 of the Social Security Act gives the U.S. Secretary of Health and Human Services the authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and Children’s Health Insurance Program (CHIP) programs. New York State has used this section of law as the basis for its Medicaid Redesign Team (MRT) initiatives that have fundamentally reshaped the health care system in New York State.
Among the important themes of our letter – from which specific policy ideas also flow – is the need to reorient the funding and policy structure when it comes to the state’s intended involvement of pre-acute, long-term, post-acute and behavioral health providers, including home care and hospice.
In recent editions of the Capitol Report, we’ve stressed for you some missed funding opportunities and imbalances that have emanated from the current 1115 waiver construct, exacerbating the discrepancies of other health care transformation or investment programs that have overlooked community care (i.e. the Fidelis-Centene conversion dollars). As you know, we’ve also worked vigorously with your offices for legislation to leverage state support for home and community care in a balanced way.
Funding imbalances are among many factors that have aggravated a well-documented workforce shortage plaguing community provider systems throughout New York State. (See the report we are sharing this month from Newsday on the struggles experienced on Long Island.) Community care providers must compete with larger health care systems for the same nursing and other staff, yet without equivalent, proportionate or commensurate infrastructure funding, nor the same degree of administrative authority or discretion to innovate and be lead entities influencing system change. The 1115 waiver can remedy this.
As we note in our multi-association letter, community care providers are “constantly framed under the [existing] waiver as ‘downstreams’ of other, ostensibly controlling entities, rather than as the primary, preventive and priority-first layers of the system,” whether financially, in the fund flows, or administratively in terms of which sectors are empowered to drive decision-making.
A longtime funding void has also prohibited community providers from investing in health information technology connectivity that is critical to meeting the imperative presented to home care, hospice and other providers as part of the very fabric of the 1115 waiver itself. Such imperatives include a reduction in avoidable hospital use under the waiver’s Delivery System Reform Incentive Payment (DSRIP) program and related initiatives like value-based payments (VBP).
DSRIP, as conceived to date, is an illustration of the inverted role imagined for home care, hospice and community care in the current waiver. This construct involves a “top-down,” institution-oriented structure, we write, not only for the flow of billions in funding through the 1115 waiver but also in administration and decision-making about how best to deliver care and improve outcomes.
As currently structured, these programs have also created incentives – both funding and authority-related – that result in existing community resources getting overlooked in the delivery of services at the very core of providers’ longstanding jurisdictional authority. This “duplication, overlap, conflict/confusion and scofflaw risk” needs to be addressed in the form of waiver amendments that create a more bilateral structure.
Such a structure will protect patients, in line with the historical intent of existing jurisdictional lines like Article 36 (the governing regulations for home care in New York State), by avoiding the kinds of patient-care safety risks that arise when other disciplines seek to overstep in providing community care.
Our multi-association letter includes a range of other recommendations related to data access, collaborative model opportunities, innovative payment arrangements and Medicare Maximization. HCA’s Policy team would be more than happy to brief you or your staff on these recommendations or any important background regarding this process. Please do not hesitate to contact us at (518) 426-8764 for further information.