The Center for Medicare & Medicaid Services’ Innovation Models supports the development, testing and implementation of innovative health care payment and service delivery models that aim to achieve Triple Aim – improving the health of the population, enhancing the experience and outcome of the patient, and reducing the per capita cost of care – in the health care system. Prompted by this interest, through Medicaid-led initiatives, federal grants and programs, and multi-payer efforts, State Innovation Models (SIM), in many states have taken root to increase the value of the Medicaid investment. These efforts range in size; from small focused pilots around specific communities or disease states, while others are more sweeping in scope and impact.
Delivery System Reform Incentive Pool (DSRIP) is one such Medicaid Innovation program. Using DSRIP states procure a Section 1115 waiver that allows the state to reward providers for implementing successful delivery system and payment reform projects. DSRIP programs in states differ in scope and the funding available but have a common focus of Triple Aim. SIM initiatives and DSRIP programs have their funds tied to meeting metrics in four main areas with a focus on improving clinical and population outcomes over time. For example, New York DSRIP program targets 25% reduction in avoidable hospital use and 90% of managed care provider reimbursements based on demonstrating outcomes (value) not volume of services with demonstrated integration of physical and behavioral health care.
Infrastructure development projects are generally focused on investments in technology, tools and human resources that are needed to providers to embark on delivery system reform journey. System redesign projects focus on fostering new and innovative models of care delivery that expand access and improve quality. Some states specify areas for clinical and population health improvement projects and associated metrics, while others allow providers flexibility to determine the key areas for improvement as well as the metrics. There is significant overlap across states between these priority areas. Further, standardized process and outcome metrics are being adopted across these programs including adoption of nationally endorsed or industry accepted metrics such as those prescribed by NCQA HEDIS®, National Quality Forum, AHRQ, Joint Commission, CMS ACO, CMS PQRS or HRSA.
PluralSoft helps Stakeholders participating in various Medicaid Innovation models implement technology infrastructure, system redesign, clinical process and population improvement projects faster, better and cheaper than building from scratch. Using CareQuotient™ (deployed in a cloud-hosted manner or on premise), and our customer-first engagement model, our world-class professional services staff with deep healthcare domain and technology expertise become your trusted partners, to deliver robust, trusted, secure, and economically scalable solutions for:
Unified Data Management Platform that enables:
- Liberation of data trapped in organizational and community data silos (EHRs, HIS, Billing, HIEs, Payer systems, Public Health registries, etc)
- Bi-directional Health information exchange across communities complaint with interoperability standards including connecting EHRs to HIEs/RHIOs
- Effective Data Governance through data quality enhancement and Master Data Standardization including Enterprise Master entity Index and Clinical Terminology Management
- Integrates claims, clinical, operational and financial to manage the Cost-Quality-Risk -Reimbursement equation for effective sustenance of new reformative delivery and payment models
Ready TO GO Analytics that reduces Time-to-Insight for:
- Quality of Care Performance focused on clinical process and population health outcomes improvement
- Provider Operational and Financial Performance to enable management of pay-for-performance or pay-for-value contracts
- Utilization, Cost and Access Performance to manage care interventions for super utilizers with a deep understanding of risk-stratified and risk-adjusted care burden at a community, organization and provider/physician levels
- Reporting Performance on process and outcomes metrics that drive funding stream allocations
Addressing real-world problems in areas of:
- Managing At-Risk Populations
- Focusing on Prevention & Safety
- Gaining Population Health Intelligence
- Reducing Potential Preventable Events
- Monitoring Utilization and Cost Outliers
- Compliance in Performance Reporting
- Continuous Performance Benchmarking