Exploring New York's Commitment to Promoting Health Equity

With the recent push for healthcare reform, state governments started to issue crucial legislation to redesign the Medicaid program. In this episode of Value-Based Care Insights, we explore the new terms and conditions of New York’s 1115 demonstration waivers. With Vanessa Guzman, CEO of SmartRise Health, we share insights into the $6 billion initiative focusing on health equity, workforce investments, and the general support of Medicaid programs. Discover how the New York program sets a precedent for other states, addresses DEI initiatives, and strategically allocates funds to improve the care delivery infrastructure and overall patient outcomes.  

• The waivers allocate $6 billion for health equity reform emphasizing workforce investments to create a “Healthcare Equity Regional Organization” to enhance resources and accountability, particularly in underserved areas.  
• This legislation strategically allocates funds to tackle social determinants of health, emphasizing a holistic approach for immediate impact and long-term sustainability.  
• As one of the first states to enact such legislation, New York has demonstrated a commitment to social reimbursement to address diverse healthcare needs and reshape policies nationwide. 

LISTEN TO THE EPISODE:

 

Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I'm your host, Daniel Marino. Over the last couple of weeks there's been a lot of great information that has come down or has come out around the 1115 demonstration waiver. And if you're not familiar with it, it's a great program. Great innovative demonstration projects that many States are involved in that really help support the Medicaid program. The 1115 Demonstration waiver refers to the section of the Social Security Act that allows the Secretary of Health and Human services to approve experimental pilot or demonstration projects that really promote the objectives of the Medicaid program. But, more importantly, it allows funding to providers. It allows providers to test new innovative approaches, if you will, to think about outcomes, and really some great benefits to a lot of the Medicaid beneficiaries.  

Well, I'm excited to kind of dive into this a little bit deeper and particularly excited to have with us today, somebody who's been on the program before. A great guest, Vanessa Guzman Vanessa, is the CEO of smart rise, health and a wealth of information when it comes to the 1115 waiver. So, Vanessa, welcome to the program. 

Vanessa Guzman:

Thank you so much, Dan. And I hope I can be a wealth of information to you all listening. This is all fairly new, and we're still synthesizing all this, all these documentations and over 200 pages of policies and and lots of words. That we now need to get working on. So I really appreciate our time together today. 

Daniel J. Marino:

Well, it's very exciting, and I and I definitely am excited to kind of dive into it. So let's talk a little bit about what recently passed in New York. You know, as part of the New York 1115 waiver somewhere in the range of 6 billion dollars was approved for providers. Can you provide just a little bit overview? And some of the things that were approved within New York? 

Vanessa Guzman:

Absolutely. So what was really approved was the New York State equity reform. You know, over 17 months of negotiations with CMS, we finally have a demonstration project that would start in April of this year through March of 2027, which really, It spans a wealth of work around improving in closing inequities, but also improving and advancing health, equity resources downstream to providers for investments, for knowledge, for workforce, and really to really put us all in sync across different stakeholders to be accountable for health equity. So we're really excited. It. Really, it really synchronize as well with other programs within CMMI, the innovation projects, but also it creates a lot of alignment with accreditation products, with many in health equity initiatives that already New York has been pushing through and advancing for so many years. So all really exciting. And we have a lot of work ahead. 

Daniel J. Marino:

As I've looked into the to the program, and I've been following this for quite some time. As well. You know, there's a couple of really key components of the program that really caught my attention. I think one of those is the ability to focus on some of the social needs of Medicare beneficiaries. I think another one is the workforce investments, to kind of invest in the expanded provider community, right? Those that are involved in some of the social needs, or community health benefit providers, and that sort of thing. The other one that you touched on a little bit is the establishment of what they're calling a health equity regional organization hero. So I'd love to talk a little bit about that. Health equity, and certainly, as it relates to diversity, equity, and inclusion is something that is really key. CMS is looking at it. And we'll be incorporating that on on some of their future value based programs. So you know, again, really exciting piece of that. Maybe we could start a little bit around some of the social needs and some of the social activities. That you're seeing related to some of the benefits that would come out of this.

Vanessa Guzman:

Yeah, the biggest win out of the waiver is really securing reimbursement for social determinants of health, and health related resources, that can be made available through community based organizations. You know, societies and other organizations that focus on social care. And of course, the integration of primary care, behavioral health, and other and other priorities like children's health. As we know, half the population and Medicaid in New York is their children. So in the future your State does hope to submit an amendment to also include continuous involvement for children down the line.  

But I think, what's really the highlight we're talking about help me relate to social needs. We're really referring to entities that provide these type of services. Right? We're talking about making sure that they're integrated, that you're building partnerships with the community from transportation to nutrition access to healthier foods, mental health, and other resources that are made available. But also within that there's other there, there, we're looking at different levels of reimbursement that would be considered like a level a level 2, but a level one could be starting with screening, right? As do we, screening, as we know it, and then, a level 3 could be more providing specific services for those that are chronically ill that are have reoccurring events of the hospital or the Ed right, those with higher risk of other chronic conditions. So it does follow the traditional order of operations that we've been we've been promoting for many years.  

Daniel J. Marino:

Now, the nice thing with that is, it seems like it's starting to connect the dots right? So you have different areas which you know in the past have been probably pretty isolated in and of itself. And now we're starting to create, you know, connect these, if you will. So providers who would have access to this level of funding, or maybe be able to participate, do you need to be designated as an FQHC? As a community based provider? I would assume you have to have some level of, you know, serving the Medicaid population?

Vanessa Guzman:

Yeah, for sure. So all the above right? So it is aiming for providers, hospitals, hospital systems, IPAs, ACOs, right? Those who provide primarily within the day delivery care within New York. However, in order to access the Medicaid Hospital global budget, the criteria is a little bit different there, right? Now, we're talking about organizations that serve a Medicaid population or uninsured of about 45% to be specific. That is the key number. And that have that are nonprofit or organizations and have relied on subsidies from the State for the past over the past 2 years, and it includes all boroughs in excluding Manhattan, which is important to know. And and but it includes Westchester. So that that is generally the overarching criteria to access the global budget piece, which again, as you all may know, is a it serves. It is about a third of where the funding is going. New York State something to know

Daniel J. Marino:

Right? Right? Right? So you know, it's really those disproportionate hospitals right? The dish hospitals who would be participating if you're an entity, otherwise it has to be an FQHC or some type of a community based organization which makes sense. Because I mean, obviously, that's where the funding is really needed. There's a lot of, you know. Free care if you will, that's been given out to Medicaid and the Medicaid population. And just really the underserved communities.

Vanessa Guzman:

Absolutely, it's being very targeted and an intentional, the topics that it would like to impact over the next 3 to 4 years.

Daniel J. Marino:

So you know, there's a lot of discussions around health equity, and in particular, around diversity, equity and inclusion. Any thoughts on how the waiver is going to address that on how we're going to create a little bit more of, say balance, and some of the care that we're delivering, or better integrate with some of the social aspects of the population or of the communities?

Vanessa Guzman:

I think existing strategies that aim to understand individuals in the workforce their needs, their career pathways, especially those with technical titles or nursing titles or front line staff, right? Things that are ready, very much promoting the value of all in whoever serves the community and individuals. I think that's still very much applies, I think, regardless of the terminology that we use. They're not very explicit, the waiver is not explicit with calling that out, but it still uses the essence of How do we value our workforce and invest in? You know, things like us loan repayments right? to ease education, and provide financial systems for many of those holding or aiming to hold some of these degrees.

Daniel J. Marino:

Well, and I and I know it's I know it's new. And maybe this is just unique to New York, although I would think it would be replicated in in other States. We could talk about that in a few minutes. But the it it's made reference in in the New York 1115 waiver. It's made reference to the Health Equity regional organization. So it seems to me that you know it's almost like a not a separate entity, but a coalition, if you will, of how we want to address, possibly health, equity for individual communities. Any thoughts on that or kind of how that would expand?

Vanessa Guzman:

Yes, so a. As by definition, the heroes which is ironic, the use of terminology. Here it does feel like a superhero, because, unlike other previous waivers, in New York, It, or even the initial proposal it. It really only refers to a single entity. And we've learned in the past. And this waiver does not include budget for like consultants and other supporting structures which we're very much used to. But the single entity essentially would be responsible for the overall design of the framework from data collection. They'll be receiving data from multiple sources and then determining what resources and basically like how to do it. The playbook, exactly to to all the organizations that are participating are impacted. So I see them really as setting accountability for equity integration, but also really important, providing guidance. And how do you align this with every other initiative, especially those who are involved in CMMI innovation. Models like aco reach like ahead, like guide for dementia patients right? Like I could keep going and going. Ncqa. Accreditation Commission accreditation. 

So they have a lot of work ahead, and I think you know things that folks can start doing now to prepare for, to for that interaction, there are immediate steps necessarily, because we still need guidance on what exactly they want us and everything else. But I think we could start creating governance right in our individual organizations to understand, how are we going to mobilize synthesize all this information that's going to come soon our way. And are we eligible for you know whether it's the global budget? Are we eligible as a community based organization? You know, what criteria doing or criterion do we need to be able to be part of all this? I think that's due diligence that can start right now. Even though a lot of the how to hasn't been worked out.

Daniel J. Marino:

If you're just tuning in, I'm Daniel Moreno, and you're listening to value based care insights I am here today with Vanessa Guzman, and we are talking about the New York 1115 Waiver impact on Medicaid program as a model for other states. So, Vanessa, when we're looking at what's occurring in New York, and I know that there's been a number of 1115 waivers that programs that are in other states. I think there's some of the range of 64, 65 on that that are that are out there. How much of this becomes a model for the other States as we start to think about replicating, maybe the hero program, or different for other areas. Or is this, you know, aligned with what's occurring with other States? And it's just all going to be taken together to determine how we become, you know, we build it into some further reimbursement or structure around serving the Medicaid population. 

Vanessa Guzman:

Yeah, no, I think it will. It will eventually serve as a model. I think much to be learned, I think, but you know New York State has emphasized evening on its waiver, that it has taken all lessons learned right? From higher waivers, including its own right, like District and other programs that have been facilitated. Data and time will tell, of course, based on outcomes that we see. I think the cool thing about New York State is that you know, within New York States, there's pocket of a lot of diversity pocket of a lot of populations across the map that really, from my perspective, reflect the rest of the country. To some extent it is a true melting pot in specific areas, but it's also very rural in urban in other areas. So there's a lot that that can be reflected and drawn from the data that's collected. But also, I'd be interested in seeing how does New York State align with these different programs, given its history and participation and advocacy and health equity before it was name health equity by the rest of the country. Right? like they've been focusing on it for very long time. So how can that influence future models and waivers? 

Daniel J. Marino:

Yeah, no. And I and I agree, and you know New York certainly is that I think it'd be a Mac microcosm for the rest of the country. But when you think about, then how to adapt some of this to say the rural health setting or other metropolitan areas? You know, I think, that alignment is going to be important. When you think about the funding, let's talk about that for a second. You know, there's quite a bit of dollars that are going to be, you know, I guess, set aside for this in New York. And you know again, I think the devils in the details, right as we think about what the participation is and how the funds become available. Can you talk a little bit about how some of the funds may be prioritized?

Vanessa Guzman:

Yeah, sure. So most of the funds, about 50% of the funds are going toward the actual SDOH or health related social needs right aspect of it growing that infrastructure. From screening to social services communication data. It's really because we're what we're talking about. How do we address the 80, 20. And really this is the 20. Right like this is the topic that really should factor or be attributed to the successes, or future lessons, as we continue. About a third of the rest of the funds is toward global budget. So you know. So we have mix mixed feelings over global budget and how it's used, but obviously depending on who qualifies and who's eligible for that, we will, we will test the waters to determine how that influences those organizations that serve those in with the greatest need. But I think the bottom line is that now we're drawing from Federal funds, State funds and really creating some structure and accountability that perhaps did not exist or will be reinforced by the program. Then about 10% or so is dedicated to the workforce component of it, which is great because the workforce is fundamental to the successes of absolutely oh, how we see and support patient care.  

Daniel J. Marino:

I mean, really where the need is. II mean, I remember, couple of years back I worked with a community based organization. And I tell you they did God's work. They were fantastic in terms of the support, and but they often said, if we only had a few more resources that we can invest to, we can even just make, you know, 5 times more of a of a difference. And I think to be able to have that level of funding to invest in social workers, to invest in folks with dietary education, right? To invest in programs that support, say, education around diabetes or high blood pressure. Boy, those that type of education and influence could really make a big difference. 

Vanessa Guzman:

It's it would be huge. And let's not forget navigation. All these have such a key influence in the ability for a patient to feel supported, but also navigating them to the resources that these programs and waivers are creating for them. As you know, based on literacy rates, whether they're non English speaking or not. Age, all of those factors play a role in determining the accessibility that one may have in obtaining those resources, even if they're right in front of our faces. So these are key roles, that need to be part of this program to be successful.  

Daniel J. Marino:

Yeah, yeah, no. I agree, how about investment in infrastructure? You know, many of FQHC's community health centers and so forth. Their funding is limited, right? But the resources is real, are really key. So when I think about resources, I think about, you know the data and the analytics. Maybe around social term of the data. I think about care management and the ability to be able to understand what's occurring with the population, I think about patient navigation and outreach. That was level, you know. Infrastructure. Where does that fit into some of the funding around the 1115 activities?

Vanessa Guzman:

That would fall certainly AR around the hero part of is the hero infrastructure. Right? Because they'll be, that's about 2% of the funds will be going there to designating that accountability structure that's needed to really provide oversight in the program. So that's oversight and governance in my head. And then the rest of the funding from my point, as you mentioned, population, health quality data aggregation, all of those would fall in in the health related social needs bucket cause that's really infrastructure to be able to support most of that. And then it's sprinkled across workforce. Because again, all these roles may be providing services that are needed to support those services that aren't highlighted. I mean, with that going to be really limited, absolutely and ideally. The you know, the goal is, and for New York it has been. The goal for many years is that the community and the patient population is very much reflected in the workforce. Right? Because that's really where we see connection, engagement and long, long term sustainability and positive outcomes of many of these programs that will be created via the waiver. 

Daniel J. Marino:

Yeah, boy, that's great. So last question that I have is is really around the alignment with CMMI. You know, the Medicaid reimbursement and a lot of the activities that occur are really on a State by State basis, and even some of the States have created, you know, their own Medicaid ACOs and so forth. In some cases it's created a little bit of a contradiction with the type of reimbursement that CMMI, or CMS has done as part of the ACOs. Any thoughts in terms of how this would align, I would assume it would be very performance based very outcome space. But do you see that alignment occurring with CMMI as we think about how to come up with more of a reimbursement structure?

Vanessa Guzman:

That's going to be tricky. I think I think there's work there. I don't have a direct answer yet on heather. How? Because nor does CMS, they're right. 

Daniel J. Marino:

Right, they're figuring out. 

Vanessa Guzman:

I you know my experience in working with New York State and DOH is that that require stakeholder engagement and conversations which is part of the hero's role, which is great because those conversations needs to occur. I remember back in the day when several of my organizations, including one which I was employed in participated in like the next generation, ACO Program, we're trying to figure out, how does that fit into the old pair program for New York State, and we had to give very explicit feedback to DOH on, We shouldn't be submitting two reports, it's the same data right? Like things like that.

Daniel J. Marino:

Right it has to be aligned, it has to be coordinated.

Vanessa Guzman:

It has to be coordinating. We shouldn't be submitting, you know, data to pairs and like 3 different entity, including CMS. So that's the level feedback that needs to kind of roll up and down.

Daniel J. Marino:

And making sure that everything is aligned it, you know, it's gonna take a while to figure that out. But my hope is that it does come together.

Vanessa Guzman:

I think, yeah, absolutely, it will come together. And an immediate next step that organizations can start thinking about is you know, if if you participate in any form of ACO or see my program. Think of the benefit enhancements that you're selecting for that for that program, because that should align with the services or the expansion of services. That per, perhaps would be provided through the waiver. We would think about, you know, how are you collecting data for quality and health equity today. How are you using z codes and collecting the Z codes right like, and ultimately, how are you screening full for social terms of health. All of those things are fundamental, and can be done now to create your own alignment while the States and the Federal Government figure things out.

Daniel J. Marino:

What's really exciting to me about this is it's brings together closer primary care and behavioral health services. And, as you said, there's a lot of things that providers could really begin to do now in preparation for that which, when it does become time to really launch, I think they're in a really great position.  

Well, Vanessa, this has been fantastic just a and we just scratch the surface right there. Just so much information here, I'm sure. If any of our listeners are interested in in hearing more about this. Any thoughts? What can you share? 

Vanessa Guzman:

We at SmartRise Health. We're about to launch a big campaign educating folks on what you should be doing now, building readiness. So be on the lookout for LinkedIn. We are LinkedIn, and we'll be posting more information there. Visit our website as well. Www. Smartrisehealth.com. Or you can email me directly, and I'll direct you to the right resources. And then there's some resources from the Kaiser family foundation that tracks across the country, you know the waivers that have been approved for pending, many of which we can share with you. So just raise your hand and ask and we'll share updates as we get them. 

Daniel J. Marino:

Well, and there's more and more information coming out all the time. We will do our best as well, Vanessa, to attach a couple of the links on the liner notes, but again, I would encourage our listeners to reach out to Vanessa through our website and to connect to learn a little bit more. It's a great program. You know, there's always, you know, in healthcare is always a number of challenges that come out, and some things we got to scratch our head around what you know, asking, or really what the intent is. This, I think, is a good one. I'm really excited to see where this is going to go, and I think this holds tremendous amount of benefit for our Medicare, or I'm sorry Medicaid beneficiaries, particularly in the New York area. But across the country. 

Vanessa Guzman:

I really believe so. In the next 3 to 4 years. Should reflect the demonstration of a lot of years and dedication of many of us who have porter hearts and soul into this work. So, Dan, thank you so much for having me again. 

Daniel J. Marino:

Yeah. Well, my pleasure. And as you're working with some organizations, maybe down the road. Love to have you back, and even maybe one of your you know your client organization, boy. I'd love to dive into that a little bit, so we'll have to plan for it.

Vanessa Guzman:

Absolutely. Thank you so much.

Daniel J. Marino:

Well, thank you again, Vanessa, this has been wonderful as always, and I want to thank all of our listeners for tuning in. Until the next insight, I am Daniel Marino, bringing you 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners