PPS Speed & Scale Commitments

Revisions to Provider Categorization and PPS Speed & Scale Commitment Targets

  • Presentation is also available in Portable Document Format (PDF)

September 30, 2015

Agenda

  • Overview of Speed & Scale Updates
  • AV Level Set – Speed & Scale
  • Revisions to Speed & Scale Commitments
  • PPS Data Files
  • PPS Network Re–opening

Overview of Speed & Scale Updates

  • In the DSRIP Project Plan Application, PPS made commitments on the number of providers in their network they would commit to meeting 100% of the project requirements for each project they were pursuing.
    • PPS also made commitments on the total number of Safety Net providers out of all Safety Net providers in their service area that would meet 100% of the project requirements.
  • Providers were organized across 12 provider categories based on a FFS claims driven logic.
  • PPS indicated concerns regarding providers being included in a category that they are not traditionally associated with.
  • DOH has revised the categorization logic to be more accurate and where possible align with the Medicaid Managed Care Operating Reports (MMCORs).
  • The revised logic has resulted in a new listing of providers that mitigates the issues experienced in the last round of speed and scale.
  • As a result of the revised logic, the total counts of providers by category for each PPS have changed, requiring updates to the Speed & Scale commitments made by PPS in January 2015.
    • DOH has developed a logic for the Speed & Scale commitment revisions that provides each PPS with relief from the January 2015 commitments.
  • Shifts to the PPS networks and provider Scale commitments are considered during IA evaluation of the Project Implementation Speed and Scale AV
Overview of Speed and Scale Updates
  • In the aggregate, the PPS counts have increased by 60,892, exclusive of any new providers added to PPS networks.
    Provider Category Old Count of Providers New Count of Providers Increase (Decrease) of Providers
    All Other 168,392 229,551 61,159
    Case Management 1,827 2,760 933
    Clinic 5,349 3,330 (2,019)
    Hospice 141 222 81
    Hospital 666 390 (276)
    Mental Health 18,337 21,201 2,864
    Nursing Home 1,116 1,038 (78)
    Pharmacy 1,385 1,579 194
    Practitioner – Non-PC 256,500 254,394 (2,106)
    Practitioner – PC 86,272 86,355 83
    Substance Abuse 2,261 2,318 57
    TOTAL 542,246 693,138 60,892
  • Only Clinic, Hospital, Nursing Home and Practitioner – Non– PC saw overall decreases in the count of providers due to the reclassification.

Revisions to Speed & Scale Commitments

  • Due to the updates to the provider categorization logic and resulting changed to the provider counts, DOH has revised the Speed & Scale provider commitments made by the PPS in January 2015.
  • The revisions to the Speed & Scale provider commitments impact:
    • The Total Number of Providers Committed by Provider Category and Project
    • The Total Number of Safety Net Providers Committed by Provider Category and Project
    • The Total Number of Providers Committed by Project
  • The revisions were based on the reclassified providers within the provider networks used for the January 2015 commitments.
    • Providers added to the network after the January 2015 commitments were not factored in to the calculation of the revised commitments.
  • The revisions to the provider categorizations and the revisions to the Speed & Scale commitments has resulted in an overall decrease to the commitment targets for each PPS and an increase to the total provider count from which to reach these commitments.
    • The inclusion of new providers in the networks has further increased the provider counts for PPS.
      Original Commitment Original Count New Commitment New Count
      (excluding new providers)      		 New Count
      (including new providers)
      292,720 542,246 264,410 603,138 631,791
    • Original Commitments accounted for 54% of the Total Provider Count.
    • New Commitments represent 42% of the New Provider Count (inclusive of new providers).
  • The Total Number of Providers Committed by Provider Category and Project has been revised as follows:
    • A PPS that had an INCREASE to their Provider Count will have a new commitment target at 95% of their original commitment target
      Provider Category Original Commitment Original Count New Count New Commitment (95% of Original)
      Mental Health 300 400 500 285
    • A PPS that had NO CHANGE to their Provider Count will have a new commitment target at 95% of their original commitment target
      Provider Category Original Commitment Original Count New Count New Commitment (95% of Original)
      Mental Health 300 400 400 285
  • The Total Number of Providers Committed by Provider Category and Project has been revised as follows:
    • A PPS that had a DECREASE to their Provider Count will have a new commitment target at 90% of their original commitment ratio
      Provider Category Original Commitment Original Count Original Commitment Ratio (300/400) New Count New Commitment @ Original Commitment Ratio (300*75%) New Commitment @ 90% of Original Commitment Ratio (225*90%)
      Mental Health 300 400 75% 300 225 202
  • Similar logic was applied to both the Total Safety Net Providers Committed to projects and to the Total Number of Providers Committed by Project. These commitments have been revised as follows:
    • A PPS that had an INCREASE to the Total Safety Net in Service Area/ Total Project Level Provider Count will have a new commitment target at 95% of their January 2015 Total Safety Net/Total Project Level commitment target
    • A PPS that had NO CHANGE to the Total Safety Net in Service Area/Total Project Level Provider Count will have a new commitment target at 95% of their January 2015 Total Safety Net/Total Project Level commitment target
    • A PPS that had a DECREASE to their Total Safety Net in Service Area/Total Project Level Provider Count will have a new commitment target at 90% of their January 2015 Total Safety Net/Total Project Level commitment ratio

PPS Data Files

  • Each PPS will receive a package with up to 3 files that contain all of the data related to the updated Speed & Scale provider categorization data and Speed & Scale commitment data. These files will include:
    • Speed & Scale Provider Counts by Type: a PPS specific report breaking down, by DSRIP provider category, the total Safety Net and non–Safety Net network providers by PPS and the total Safety Net providers in a given service area. This file includes Old Speed & Scale Counts, New Provider Counts, Variance between Counts, and New Provider Commitment Targets.
    • Entity ID/NPI/MMIS Crosswalk file: a PPS specific listing of Entity ID mapped to MMIS and/or NPI, so that PPS can identify providers in SIM or MAPP tools.
    • Total Safety Net & Non–Safety Net Network Provider Counts (ONLY for PPS pursuing project 2.d.i): PPS specific listing of all Safety Net and Non–Safety Net providers per PPS and a listing of all Safety Net providers in a PPS region.

Speed & Scale Next Steps

  • PPS will have an opportunity to request a review of the categorization of specific providers in the event the revised categorization logic did not align a provider as a PPS would have expected
  • The development of a list, by PPS by DSRIP Provider Category, of the providers that were lost in the biggest losing categories.

Reopening of the Performance Network

Opening of the Network

  • The Performance Network will open October 23rd and will close Friday, November 20th at 4 PM
  • PPS will be allowed to add new providers, but will NOT be able to delete or modify information for providers already in network
    • Because providers cannot be deleted once added, it is crucial that PPS enter the NPI/MMIS IDs and Provider Names into the MAPP tool accurately
    • DOH will allow certain modifications to information about providers already in network at a later time
    • PPS may only be able to remove providers during mid–point assessment

The Unaffiliated Provider List

The DOH will be distributing the New York State Unaffiliated Provider Lists to the PPS by 10/02

  • Unaffiliated providers are providers that are currently NOT participating in the DSRIP program and are NOT in a PPS network

                      ↓

PPSs can use these lists as a means to identify, contact, and partner with providers

  • PPSs will have a six week period before the performance network closes to engage these providers

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PPS must have letters of attestation on file for any provider they add

  • The PPS can be audited by OMIG at any time to review attestation records

Unaffiliated Provider List: Understanding the Data

  • A single provider can be listed in two or more provider categories and so would appear in multiple tabs
    • This methodology is similar to the Speed and Scale provider count tables
  • Because providers can have multiple addresses – or no address at all – associated with their NPI or MMIS IDs, the address that has been tied to a given provider may not always be the most accurate address

Unaffiliated Provider List: Understanding the Member Counts

  • The Medicaid member count in the document shows that a give member had at least one claim with a given provider, but does not designate the number of claims the member had with a provider
    • For example: Joe has 10 claims to Hospital XYZ and Jane has 1 claim to Hospital XYZ. Joe and Jane will each show up as only 1 count on the Excel Pivot table.
  • Although a member had a claim with a provider, it does not guarantee that the member would be attributed to the provider for performance
    • A member could have more visits with another provider or could match with another provider on a higher level in the attribution logic

Adding Providers with the New Provider Template

PPS will NOT have the ability to upload network lists into the tool (all additions and modifications will have to be done provider–by–provider).
  • In instances where a PPS is adding many new providers to their network, the PPS will have the opportunity to submit a "New Provider Template."
PPS that elect to use the New Provider Template will have their networks locked as the template is QA´d and then uploaded into the MAPP tool. Upon the DOH receiving the New Provider Template, a PPS´ network will be locked for the remainder of the network reopening period.
  • PPS will not have the opportunity to send any additional New Provider Templates, this is a onetime approach.
The template would need to be submitted to the State by email (dsrip@health.ny.gov) by 4:00 pm on Monday, November 16th.

Receiving the Files Through the DSRIP Digital Library

  • Who is a PPS Digital Library user?
    • All HCS PPS MAPP users are also DSRIP Digital Library users
    • These users should have received the link, username and temporary password to access the Digital Library via an email sent by CMA on 09/10/2015
  • What document will PPSs receive through email?
    • The New Provider Template
  • What document will PPSs receive through the DSRIP Digital Library?
    • The Unaffiliated Provider List
      • The Digital Library user can access these documents and disseminate to others
  • Where can PPS find the relevant documents?
    • File Hierarchy: PPS Specific Site > Attribution, Valuation and Network folder
    • A PPS can only access the Home Page and their PPS Specific folder on the Digital Library
      • Other PPSs’ folders will be visible to the PPS, but NOT accessible
  • If PPSs have technical issues please contact the CMA help desk at 518–649–4335

DSRIP e–mail:
dsrip@health.ny.gov