DRIS Evaluation, Methods and Preliminary Cross–Cutting Themes

by Ira Moscovice, Ph.D.

Moderator: Luisa Buada, Executive Director, CIRHM

DRIS Evaluation Components

Qualitative assessment of the implementation of DRIS at five sites through the completion of intensive case studies

Testing the underlying assumptions of DRIS
Synthesizing key factors that influence DRIS site operations
Assessing generalizability of DRIS process to other rural environments

Quantitative assessment of the impact of DRIS on health providers and residents in participating rural communities

Monitoring intermediate markers of system integration (using data collected via provider survey to be fielded initially in February and March, 1999 and re-fielded at the end of the project)
Measuring local retention of health care expenditures (using Medi-Cal and Medicare claims data and OSHPD data for the time frame of the project)

Quantitative assessment of the impact of DRIS on health providers and residents in participating rural communities

Analyzing site functions with respect to the organizational structure of the accountable entity, level of provider participation and outcomes achieved (using function-specific data collected from key contacts involved with implementation)

DRIS Evaluation: Cross-Cutting Themes

The DRIS process provides a structured framework for broad segments of rural communities to address health care delivery and financing issues in an evolving managed care market place.
DRIS sites progress at their own speed. The DRIS process has to be flexible to accommodate differences in site needs, time lines, driving forces, and threat of managed care penetration. Key site factors affecting progress include:

Quality of site leadership
Organization, stability and commitment of local providers
Level of community involvement
Perception of environmental threats particularly as they relate to managed care
Historical relationships and current level of trust among key site participants
Community demography and economy

Service area definition (e.g., multiple counties with a diverse set of needs, sub-county with substantial history and competition among providers and a limited population) can influence the progress and likelihood of success of the development of integrated rural delivery systems.
External catalysts play multiple roles that evolve over time in the development of integrated rural delivery systems including educator, data collector/analyst, neutral convener, mutual arbitrator, provider of technical assistance, and funding source for capital expenses.
Most sites valued the data-driven and broad community input emphases of the DRIS process. A pre-planning phase that involved data collection and analysis could help shorten the Phase I time line for community participants.
Timely data can be used to inform decisions but doesn’t de-politicize the decision-making process.
There was a substantial positive psychological impact of having well-defined milestone grants.
Rural employers are very interested in capping their financial risks associated with employee health costs, which implies rural health providers may need to assume more risk. Rural employer acceptance of changes in health benefits packages or health benefits administration is open to question.
The definition of community representation varied by site, as did their acceptance by providers and employers in the health care decision-making process.
The degree of local ownership of the change process is inversely related to the amount of control and support exerted by external entities. As the level of external support is reduced over time, communities will need to identify an entity that will be responsible for making decisions about the local health care system.
The selection and implementation of functions is a big hurdle for the DRIS sites. There is primary interest in developing ASO/CHO type functions (e.g., claims administration, QA/UM, credentialing, marketing, case management, information systems linkages) that involve limited provider risk.
In addition to the direct effects of function selection and implementation, there have been positive spillover effects of DRIS including the receipt of additional health related grants and the use of the community council structure to address other important community issues.
It is difficult to develop a replicable managed care product for rural environments. Clear delineation of acceptable functions and markers of progress at DRIS sites will improve the chance for replicability.
The future implementation of functions at DRIS sites will need to be coordinated with the availability of support from a range of funding sources.

System Integration Markers

Components Of Clinical Integration

Use the same physician credentialing system
Use the same quality measurement and improvement program
Use the same clinical protocols developed or approved by local practitioners
Use a system for sharing medical records
Share diagnostic services/equipment
Jointly provide clinical services (e.g. prevention and wellness, primary care, acute care)
Jointly develop referral mechanisms
Jointly provide coverage and call

Components Of Functional Integration

Human Resources

Use the same personnel policy manual
Use the same salary and wage system
Use the same health professional recruitment program
Use the same continuing education programs (e.g., for doctors and nurses)
Use shared staff (e.g., nurses, physical therapists)

Accounting

Use the same chart of accounts
Joint efforts for payroll and/or accounts payable
Joint efforts in patient billing and collections
Participate in group purchasing

Planning and Marketing

Joint efforts in marketing and community relations
Joint strategic planning activities (e.g. needs assessment, product development, budgeting)

Governance

Serve on each others boards

Management Information Systems

Use the same management information system (financial, clinical)

Components Of Financial Integration

Accept a portion of the risk of operating loss on joint ventures
Accept a portion of the risk of business failure on joint ventures (i.e., responsible for paying creditors if business fails)
Contribute capital to joint ventures
Jointly contract with third party payers (commercial insurers, Medicare, Medi-Cal)

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