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Adirondack Medical Home Summit 2013: NYS Reform. Foster Gesten, MD, FACP Office of Quality and Patient Safety. Overview. Medicaid Reform Health Exchanges Primary Care: PCMH and beyond State Innovation Model (SIM) Quality and Patient Safety Prevention Agenda. Overriding Themes.

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Adirondack Medical Home Summit 2013: NYS Reform

Foster Gesten, MD, FACP

Office of Quality and Patient Safety



  • Medicaid Reform
  • Health Exchanges
  • Primary Care: PCMH and beyond
  • State Innovation Model (SIM)
  • Quality and Patient Safety
  • Prevention Agenda

Overriding Themes

  • Integration
  • Care Management
  • Care and Payment Reform
  • Alignment
  • Data (to information to action)
  • Transparency
  • Triple Aim

Medicaid Reform

  • Managed Care for All
    • SPMI
    • LTC
    • Duals
    • Foster care
  • Care Management for All (that need it)
    • Health homes
  • Global Cap
  • Value Based Benefit Design
    • PCI
    • Preterm births
    • Evidence based review of benefits

Health Insurance Exchange

New York State of Health


What is NY State of Health?

  • Organized marketplace
    • One-stop shopping for subsidized and unsubsidized coverage
    • Easily compare health plan options
    • The only place to check eligibility and apply for financial assistance
    • Enroll in qualified health plans
  • Two programs
    • Individual Marketplace
    • Small Business Marketplace

Who Will Enroll In NY State Of Health?

Health Plan Marketplace enrollment is estimated to be

1.1 million New Yorkers


Health Plan Highlights

  • Choice of plans in all areas of the State
  • Increased competition gives consumers new health plan options
  • Premiums for people who buy coverage for themselves and their families decreases by an average of 53% compared to today’s premiums
  • You will not be denied health insurance on the basis of a pre-existing condition
  • All plans are required to have adequate networks

Required Ten Essential Health BenefitsPreventive services will be offered at no cost to you

  • Ambulatory patient services
  • Emergency room services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorders
  • Prescription drugs
  • Rehabilitation and habilitation services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision

Financial Assistance

  • Many individuals and families will be eligible for financial assistance to reduce the cost of coverage
  • Financial assistance is available in 2 forms:
    • Tax credits will reduce the cost of premiums for most single adults earning less than $45,960 and for families of 4 earning less than $94,200
    • Cost-sharing reductions will lower co-payments and deductibles for single adults earning less than $28,725 and for families of 4 earning less than $58,875
  • Tax credits and cost sharing reductions are estimated at the time of application and applied immediately

Primary Care

  • Medicaid Incentive
    • Impact
    • Future direction
  • Hospital Medical Home Demonstration
  • Multi-payer Demonstrations
    • ADK
    • CPCI
    • SIM

State Health Care Innovation Plan

  • CMMI challenge to states: beyond ‘demo’ and pilot
  • Value based model of care/payment covering 80% of population within 5 years
    • Multipayer
    • ‘transformative’ care delivery and payment innovation
  • Disseminate and ‘connect’ demonstrations and innovations
    • ACO
    • Waivers
    • HIT/HIE
    • PCMH
  • Basis for Testing Grant application (up to ~$60 million)

Proximate Goals

  • Refine coherent, more detailed plan with internal and external stakeholder engagement
    • Interagency alignment (DFS, DOH, Civil Service, OMH, etc.)
    • Payers, providers, associations
  • Review with wider set of stakeholders
  • Finalize and submit SHIP
  • Convert SHIP into application (early 2014)

Core Elements

  • Care model
  • Metrics/reporting
  • Payment model
  • Transformation support
  • Benefit design
  • Workforce strategy

Quality and Patient Safety

  • ‘New’ Office of Quality and Patient Safety
    • Hub for department on Q/S initiatives
    • Advance use of data for improvement, evaluation, prioritization, transparency, accountability
      • LTC
      • Physician practices
    • APD
    • Sepsis
    • Cardiac services, Stroke, Office Based Surgery

Make New York the Healthiest State

New York State Prevention Agenda


Prevention Agenda 2013-2017

  • Goal is improved health status of New Yorkers and reduction in health disparities through increased emphasis on prevention.
  • Call to action to broad range of stakeholders to collaborate at the community level to assess health status and needs, identify local health priorities and plan, implement and evaluate strategies for local health improvement.


  • Local Health Department Community Health Assessment & Community Health Improvement Plan
    • Due November 15, 2013; covers years 2014-2017
  • HospitalCommunity Service Plans
    • Due November 15, 2013, covers years 2013-15
  • LHDs and Hospitals asked by Comm. Shah to work together to assess health status, select common priorities including one to address a health disparity, and develop and implement a plan to address priorities.

Prevention Agenda 2013-2017: Ad Hoc Leadership Group

  • Six members of Public Health Committee and other leaders from Healthcare, Business, Academia, Community-based & Local Health Departments.


Ad Hoc Committee considered:

  • Urgent Health Issues and Disparities in NYS
  • Experience with first Prevention Agenda
  • Factors that contribute to health

Framework for Improving Health

Frieden T., A Framework for Public Health Action: The Health Impact Pyramid.

American Journal of Public Health. 2010; 100(4): 590-595


Five Prevention Agenda Priorities

  • Prevent chronic diseases
  • Promote a healthy and safe environment
  • Promote healthy women, infants and children
  • Promote mental health and prevent substance abuse
  • Prevent HIV, sexually transmitted diseases, vaccine-preventable diseases and healthcare associated infections

For each priority area:

  • Focus Areas
    • Goals
      • Measurable Objectives
        • Interventions
          • By Sector
          • By Health Impact Pyramid


Statewide Update

  • Communities completing community health assessments and community health improvement plans due November 15th
  • Technical assistance being provided by statewide and regional organizations
  • Communication tools being distributed to local partnerships for use in engaging stakeholders
  • Meeting with foundations to seek funding to support local partnerships.
questions contact information fcg01@health state ny us 518 486 6865

Questions?Contact Informationfcg01@health.state.ny.us518-486-6865