New York’s 1115 waiver: Into the initiatives

In part one of our series, we explored the background and foundation of the New York state’s 1115 Waiver amendment. The next part of the New York Health Equity Reform (NYHER) waiver takes on population health, and you'll notice a recurring theme within these initiatives, which focus on health equity and disparity, population health and advancement of value-based care (VBC) program initiatives. 

There are three main initiatives with a goal to look at the system as a whole to provide essential services and improve health outcomes for the community. 

First is the Medicaid Hospital Global Budgeting Initiative, funded at $2.2 billion. The goal is to help financially distressed hospitals by stabilizing and transforming each organization in such a way that it has the chance to advance health equity and improve population health in communities where there has been longstanding evidence of health disparities. The incentive funding is tied to payments centered around transformational activities and quality improvement measures.

The Primary Care Delivery System Model (funded at $492 million) is geared towards advancing primary care and enabling providers to move toward advanced VBC arrangements. This is authorized outside of the 1115 waiver through a state directed payment (SDP), and funding includes enhanced monthly payments for all Patient Centered Medical Home (PCMH) primary care practices for its Medicaid members over the next two years, with subsequent years transitioning to a bonus payment structure. The enhanced payments are in addition to the monthly PCMH payments currently received by PCMH-recognized practices and align with the Centers for Medicare & Medicaid Services’ (CMS) Making Care Primary Model, which is similar to the Primary Care Delivery System model but differs in program timing alignment and member population. The former is Medicaid-focused, and the latter is Medicare-focused.

These initiatives align with the CMS All-Payer Health Equity Approaches and Development (AHEAD) model, which builds on existing state-based models dependent on the collaboration between various community organizations and community-driven strategies to improve population health and reduce health disparities. The model consists of three main components:

• Cooperative agreement funding to support initial investments for planning activities 
• Hospital global budgets to encourage hospitals to eliminate avoidable hospitalizations and improve care coordination
• Primary care AHEAD aligns with ongoing Medicaid transformation efforts and aims to increase Medicare investment in primary care

$125 million of the incentive funding is for the Health Equity Regional Organization (HERO) initiative, which is a contracted independent statewide entity made up of stakeholders designed to develop New York’s plan to advance health equity and reduce health disparities across the state. These stakeholders will be responsible for:

• Data aggregation
• Regional needs assessment and planning
• VBC design and development
• Program evaluation

The last part of the waiver is a workforce development program, which could be a much needed answer to increasing the capacity to address the growing demands for social needs and labor demands of this waiver. This program is geared toward a spectrum of roles and for both individuals who are new to the healthcare workforce as well as those who are already in the workforce to ensure everyone has an opportunity to start and continue their education.

There are two key pieces to this part of the waiver:

1. The Career Pathways Training (CPT) overseen by Workforce Investment Organizations (WIOs) received $646 million in funding. These WIOs are pre-existing organizations that will support the program through partnerships, outreach and coordination of the educational programs. 
2. A student loan repayment program specifically targeted to the clinical workforce (e.g., psychiatrists, primary care physicians, and nurse practitioners), which will receive $48 million.

Both programs will likely be warmly welcomed by the New York state healthcare workforce and play a key role in the success of the rest of the waiver which relies heavily on a strong and resilient workforce. 

So, what's on the horizon for New York? Below is a projected timeline of key milestones for the 1115 NYHER waiver in 2024:

• Social Care Network request for application released in January and due in March 2024
• Enhanced PCMH payments began, MCP practices selected, and health related social need (HRSN) implementation plan in April 2024
• HERO planning work began in June 2024
• Social Care Network contracts executed, AHEAD applications due, and CPT program began in August 2024
• HRSN services began in October 2024
• Student loan repayment applications released in late 2024 to early 2025

Once these are completed, further program development will still be needed. Since the waiver expires at the end of March 2027, time is precious with only half the time for development and implementation compared to the last Medicaid waiver that was a 6-year program. New York State Department of Health will need to determine key players, train and educate organizations on newly funded services, and implement proper billing for these services. There’s also the need to figure out how to coordinate the technological avenues and compile it in such a way that will help with impact analyses and future program decisions. 

Although the main components of the waiver have been outlined, additional strategy, implementation and operational development by New York is still necessary, and there are some instances where approval from CMS will be required before moving forward. There are a few unknown details at the moment that need to be ironed out and only time, albeit a short amount of time, will tell us how implementation will look over the next three years as well as what sticks around after the demonstration period has ended. 

Tam Stavrowsky is a lead consultant, regulatory and payer solutions, at Solventum.