LGBT health care nonprofits foresee DSRIP problems amid success

Millions of dollars in grant money for expansion projects and fresh program funding has rolled in for providers specializing in LGBT patient care in New York. Callen-Lorde will open two new health centers and Apicha is renovating and expanding its main site even as it opens another health center in Jackson Heights. But executives at both organizations and others providing LGBT services say the funds don’t address deeper problems with Medicaid reimbursement that could shutter specialized nonprofit health care providers in the future.

“It doesn't threaten my existence tomorrow, but I'm worried about three years from now,” said Wendy Stark, executive director of Callen-Lorde Community Health Center, New York City’s largest LGBT-focused health care nonprofit.

The problems posed by this new Medicaid system are complex, nuanced, and admittedly arcane, health care nonprofits and Delivery System Reform Incentive Payment (DSRIP)-involved health care professionals said. This complexity masks potentially ruinous outcomes, they said, even if health care nonprofits are not suffering any acute pain at the moment.

LGBT health care providers are worried that if allowances are not made in the reimbursement procedures for smaller health care organizations like theirs, in the near future, doctors may become hamstrung by bureaucracy and already-vulnerable patients will suffer.

These problems do not only impact LGBT health care providers, community health care nonprofits say. They are ingrained issues that impact many other community-based organizations as well. However, the complications are likely to be most acutely felt by smaller health care providers that serve targeted populations with specific needs.

The DSRIP program is an immense project to overhaul Medicaid in New York. Broadly, DSRIP’s goal is to create a collaborative network of health care providers serving the poor who will stop competing with one another and instead work together to create better health outcomes for patients – all while reducing wasteful spending. To promote this, Medicaid will move away from a system that reimburses hospitals and health care providers for the total services rendered and toward a system that reimburses them according to patient health outcomes – more money for healthier patients and less money for unhealthier patients.

Most nonprofits agree that the LGBT population faces a daunting set of health care challenges, and research supports this. If Medicaid’s “value-based payment” model does not account for providers specializing in serving such groups, those providers are bound to suffer from underfunding.

“If you are serving a population that is very difficult, that requires a lot of support services, our concern is that whatever the value-based payment is, it's got to be able to capture the appropriate amount of money that's required to serve that patient,” said Gertrudes Pajaron, chief development officer at Apicha, which primarily serves Asians and Pacific Islanders, the LGBT Community and individuals living with and affected by HIV/AIDS.

LGBT patients generally prefer specialized LGBT health care providers, nonprofits say. In fact, research shows that continued discrimination and insensitive care by medical professionals unfamiliar with the particular needs of this community have made some LGBT people less likely to go to a doctor at all. Still, LGBT health care nonprofits only serve a fraction of the overall estimated LGBT population in New York.

According to a 2013 analysis by the Williams Institute, there are over 580,000 LGBT adults in the state. Two principal nonprofit providers that target this community in New York, Callen-Lorde and Apicha, only serve an estimated 17,000 and 4,400 patients each, respectively – roughly 3 percent of the LGBT population.

As a result, both organizations say that they have an overwhelming demand for their services. Callen-Lorde has to turn away roughly 20 patients a day because it doesn’t yet have the physical capacity to serve them all. Apicha, meanwhile, has been adding 100 new patients a week, counting on incoming grant money and upcoming expansion plans to meet the need.

"Part of the reason patients come to Callen-Lorde and don't go to a larger institution, a more mainstream institution, is because they trust us. They want to go to a place with a specific mission because they've had bad experiences elsewhere.”

Stark said that she knows LGBT patients who, even in the midst of a medical emergency, “refuse to go to an emergency room for fear of the kind of treatment they might experience there.”

The vast majority of LGBT people seeking medical care will inevitably be served by physicians who are not LGBT-specialized, however the New York State Department of Health is requiring that the medical community increase its “cultural competency” – a watchword for LGBT-sensitive health care services.

The most common issue facing DSRIP-involved LGBT health care providers is that the patient populations they serve are geographically dispersed – a fact that puts them at a disadvantage to collect Medicare reimbursements, providers say.

“Our patients come to us from all five boroughs and beyond,” Stark said, noting that nearly 10 percent of the patients Callen-Lorde serves come from out of state. “And so, we don't have a bulk of patients attributed to one particular DSRIP network, which means that we get less money. And that has everything to do, I'd say, with us being an LGBT-focused health care center,” she said.

Another issue Stark points to is the smaller size of LGBT health care providers. Nonprofits like hers have far fewer staff members to deal with the additional administrative burden the DSRIP rollout requires of all health care providers.

The overhaul of Medicaid has sent a flood of paperwork to health care providers’ desks and blocked out tens of hours a month on senior staffers’ calendars for meetings to coordinate the rollout of the reforms. Health care executives said these burdens weigh heavily on nonprofit community health organizations, which run leaner operations with far fewer administrative staff members to do the extra work.

Apicha, a smaller health care nonprofit whose primary care patient base is 70 percent LGBT, estimates senior staff spend about 20 hours a month in DSRIP meetings. 

"It is a lot,” said Phillip Miner, director of grants and communications at Apicha. However, the extra work comes with a silver lining. "Because we are the small guy, it allows us to be in the room with the big guy. That's what we've focused on as the benefit for the moment,” he said. "That's how we justify it."

Apicha has also been the beneficiary of millions of dollars in grant and award money that has allowed it to expand and increase patient caseloads even as administrative demands from DSRIP increase.

The organization has found the state to be responsive to their concerns – to the tune of a $6 million Vital Access Program award it received in 2014 to build up its financial and operational capacity.

“If the grants that they gave us were to be used as a measure of that, yes, it looks like they are hearing what we are telling them,” said Pajaron. 

But concerns about the future remain.

“All I know is that the money for reimbursement will go down, rather than go up. That seems to be the trend,” said Pajaron, who carefully couched her concerns in optimism. “But we're not there yet.”

“An incredible time suck is necessary to make this work,” said Bob Hayes, president and CEO of Community Healthcare Network, a nonprofit that runs a number of LGBT-specific programs at its 11 health centers, serving 75,000 patients in New York City. Hayes added wryly, “It could be useful to do things … like see patients.”

“As the CEO here, I've said, ‘Take it easy. We can't be at every meeting they call,’” Hayes said. “The hospitals have armies of administrators. We don’t. And I can't afford to have my doctors going to these meetings and not seeing patients.”

A senior member of the DSRIP Mount Sinai Performing Provider System (PPS), one of four local planning and DSRIP implementation committees for Manhattan, spoke with New York Nonprofit Media on the condition that he not be quoted. He said the local DSRIP machinery works hard to accommodate LGBT and other niche health care providers, but that the state health department has been inflexible in how it structures the Medicaid reimbursement.

Hayes, however, lays the blame on large hospitals and academic medical institutions, like Mount Sinai, that are at the helm of local DSRIP PPSs.

“The state has opened up the flow of dollars, but the bureaucratic leadership of the PPS is moving like a glacier in getting funds to the community,” said Hayes.

Is this “going to sabotage an efficient health delivery reform? Absolutely. Of course this will sabotage it,” Hayes said. “I do think that the Cuomo administration has to step up and begin to put a bit more assertive pressure on the academic medical institutions."

“Without those funds, health reform is not going to happen in New York,” he added.

Charles King, president and CEO of Housing Works, would argue that special considerations should be made for community-based organizations to help insure the specific needs of target populations are addressed. 

"Here's what I would say. This is not a problem of LGBT (health care providers), this is a problem of community-based organizations, which might have a disparate impact on LGBT-specific organizations,” King said.

King aims to build an accountable care organization that would cater to the unique challenges facing LGBT health care providers. While the launch is planned in the next two months, he declined to name which organizations will be participating.

“We have been very strong proponents of … creating a single, statewide, accountable care organization under the value-based payment model. It would take responsibility for lives statewide of people living with HIV, MSM (men who have sex with men), transgender, people who inject drugs, and negative partners in HIV discordant relationships,” King said.

He hopes an organization where smaller, similar health care providers can cooperate could give them more influence.

"The idea is that every provider within the system would have an ownership stake,” King said. “It will actually put folks who serve certainly the MSM and transgender population in a preferred place in the whole structure.”