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Politico NY: Community groups worry about being left out of Medicaid reform

By Dan Goldberg, 1/28/16

Anthony Feliciano is popular these days. He is the director for the Commission on the Public’s Health System, a Manhattan-based nonprofit that advocates for medically underserved populations.

In that role, he has been approached by several of the largest health systems in the state, which have asked what the community he serves needs to improve its collective health.

Feliciano spends a few minutes on the phone and patiently answers their questions.

He’s told they might follow up. Some do, some don’t.

The state’s largest health systems have a renewed focus on population health because of the Delivery System Reform Incentive Payment program, a $7.3 billion plan to change how health care is delivered.

The goal of the program is to reduce avoidable hospitalizations by 25 percent over five years, which means hospital administrators need to reach people before they walk through their door.

The program was set up to encourage groups of providers to work together, including hospitals, physicians and community-based organizations — like Feliciano’s — that serve special populations within a community.

Working with community-based organizations was a requirement laid out in the program. But Feliciano says he came to realize that his brief phone calls amounted to a health system’s idea of engagement.

“When I started asking more folks about their experiences, some of them were saying similar things,” Feliciano said. “I was shocked that they would use that low of a [bar] for engagement, and they can report back to the state that they are engaged with community groups and it seems OK.”

Feliciano was one of about three dozen representatives from community-based organizations who came to Harlem on Wednesday to discuss how they can help the state achieve its goals, how they can command the attention of the big health systems and how they can benefit from the billions being doled out to providers.

At stake, they say, is not just the success of the state’s most ambitious health reform, but also their ability to effectively serve their communities. They need funding to transition their delivery services, too.

The state’s program is structured so that all the money — billions of dollars — flows through 25 performing provider systems. The lead of each system wields enormous influence over how to accomplish the dozen or so projects that state health officials say are needed to transform Medicaid.

And 23 out of the 25 leads are hospitals, prompting lawmakers, health advocates and, especially, community-based organizations to worry they will be marginalized.

Part of the problem is that there is no standard definition for a community-based organization. It might be a Federally Qualified Health Center, with millions of dollars in revenue and a large staff, and it might be an asthma group that focuses on one neighborhood and employs 12 people.

There is also no agreement on the definition of “engaged.”

Last week, several performing provider systems presented a progress report before the Progress Advisory and Oversight Panel, a citizen group meant to provide a check on program. Most of the presenters believed they had engaged community-based organizations, but most of those who spoke on Wednesday felt ignored.

Both can be right.

The disconnect comes in part because $7.3 billion disbursed among 25 groups over five years really isn’t enough money to keep everyone happy, and because both hospital administrators and community-based organizations believe they are the experts at population health.

“There hasn’t been a real conversation about what keeps people sick,” Feliciano said, “and only the organizations that have been doing this for so long can address that.”

The conversations have left many  community-based organization leaders torn. They are thrilled that the large health systems — Mount Sinai, New York Presbyterian, Montefiore — are asking for their advice and input. But they fear the health systems will co-opt their ideas and ignore the organizers and advocates who’ve made those models work.

“They should not just say, ‘let me pick your brain’ and then there is no follow through,” Feliciano said. “They cannot succeed without the CBOs.”

If a health system does choose to contract with a community organization for services, it has enormous leverage because it has all the money and teams of lawyers and administrators at its disposal.

Feliciano said he has held three training sessions just dealing with contracts.

Several of the representatives who attended Wednesday’s meeting signed a letter to state Medicaid director Jason Helgerson, asking for more money so that these organizations could engage in strategic planning, and to complain that they have so far been ignored.

“[I]t is evidently clear that there is little or no movement by most PPSs to incorporate CBOs in the planning, implementation, and funding for the chosen projects,” the letter said. “The critical timing to make a difference is almost gone. This is a seriously unfortunate concern about timing, accountability, and the appropriate use of PPS funds.”

Helgerson heard the same from Assembly health committee chair Richard Gottfried during a budget hearing on Monday.

“My concern is that if you ask a question about hospitals, you get an answer with references to hundreds of millions if not billions of dollars, and if you ask a question about community based organizations and primary and preventive care you get an answer about goals and standards we’re going to hold them to,” Gottfried said. “I’m looking for hundreds of millions of dollars.”

Helgerson said the funding for those groups is “quite substantial,” and has repeatedly said he’d like to see community groups involved in the process.

“We have to find a way to transition from a system that relied far too heavily on traditional providers to one that relies on the community,” Helgerson said Monday.

But once the checks are out the door it’s up to hospital leaders how to spend to the money.