Let’s talk about competition for a moment. As a result of its approach, the NYS Department of Health received fifty DSRIP design grant applications covering 11 regions in NYS. Although the state urges collaboration to reach the point where there’s just one Performing Provider System (PPS) per region, only five of eleven regions have just one PPS today. In fact, we have five PPSs in WNY. In NYC, there are twenty.
Clearly the state’s goal is not reality in the field, at least not this quickly. Many of the lead organizations have been bitter rivals historically. It’s unclear to me whether the state will award design grants in a way that forces team mergers, or whether they’ll allocate Medicaid patients proportionally and let PPSs compete within a region. While competition could be seen as breeding duplication of service (wasteful among not-for-profits), it’s easy to forget that this is a pay-for-performance incentive program.
Incentive for what? Both for taking on more programs, and for delivering effective strategies. On this second point, I think there’s a lot of room for competing PPSs within a region. DSRIP is an experiment that tracks outcome performance and the money spent on it. Even though there may be a wide variation in the size of competing PPSs in a region such as WNY, couldn’t a smaller PPS with an innovative and more effective program teach it to others? A rising tide lifts all boats.
We’re still missing competition from the patient’s perspective. I understand that NYS Department of Health expects to assign each Medicaid patient to a single PPS, reducing choice (if you don’t want to move to a different region). This also leaves a lot of questions open. What happens if you feel that the PPS failed you? Is there an appeal process to get a different provider? Will changing providers in the same PPS be enough to overcome the problem? How quickly can you get a different provider? What pressure makes sure your dissatisfaction gets included in metrics to the state, since PPSs self-report?
From the collaborating provider’s perspective, things could be just as difficult. Imagine you’re a provider located in a rural county in WNY. All five PPSs in your region are strongest in urban parts of Erie and Niagara Counties. Does that mean you’ll be participating in several PPSs so they can cover rural patients? How will you manage separate processes and systems for several Medicaid patient pools without losing money from the administrative burden?
I think these kinds of problems need to be worked out during the program design period between now and March, 2015.