Welcome Back Kotter: New York’s next 1115 Waiver


Months after the concept paper was published, I’ve finally edited my initial response in anticipation of a revised proposal and public comment period that will soon occur. I’ll likely author formal comments and will submit them to NY and/or CMS. I expect that my comments will mirror those below – at least in structure.

Perhaps others will find this framework helpful in the development of their own comments – hence my posting of them today.

New York’s DSRIP program succeeded in many ways and failed in many ways.  I experienced both of these, as the CEO of one of the 25 Performing Provider Systems (PPS) in the state.  This essay is my personal view – and while I do still have an advisory relationship with Alliance for Better Health and Healthy Alliance IPA – I am no longer the CEO of either entity.  These comments are therefore explicitly mine – and don’t necessarily represent the organization.

Let’s start with some context.  What did DSRIP 1.0 get right?

The program’s goal was to improve the health of New York Medicaid Members.  As a consequence – “preventable utilization” of medical services and therefore cost would be reduced. With this goal in mind, organizations statewide were formed with benevolence, collaboration, and engagement as guiding principles.  This is good. I am certain that the lives of many people were improved and even saved by the efforts facilitated by DSRIP.

Yet we also missed many opportunities to do better.  The causes of our missed opportunities were many – but I’ll outline a few as this will help guide our reading of the framework proposed for the next iteration – the Kotter Edition – named after the 70’s era TV show.

What was wrong with DSRIP?  Too many and too few.  That’s all.

  1. Too many.  
    1. Too many organizations.  Managing 25 PPS – many of which overlapped each other in geography – was an administrative challenge both for DOH and our communities.  It made DSRIP look and feel like a competition where PPS overlapped, and diminished the opportunities for whole communities to come together and solve fundamental challenges in how the needs of Medicaid members and the uninsured could be met.
    2. Too many targets.  The objectives of DSRIP 1.0 – a laundry list of HEDIS measures – made the program difficult to manage “on the ground” and too tightly tied to medical measures of success.
    3. Too many choices.  PPS were given choices about which projects they would work on – and by extension – which projects would be funded and measured. The projects were tactically expressed – and therefore too prescriptive – not just defining goals to be achieved – but presuming that DOH knew how goals would best be achieved.  In many cases – this mismatch between what to do and how it would be done was the cause of great frustration.  While DOH and CMS looked for accountability, they actually handcuffed the program by instantiating accountability as prescriptive demands that simply didn’t fit the reality on the streets.  Any innovator knows that learning and agility are imperative guiding principles.  This was largely absent from the program –  it was waterfall from the start.
    4. Too many dollars (going to the wrong places).  This is likely the paragraph that will get me in the most trouble. Here goes:  the front-loading of the DSRIP program caused dollars to go to PPS sponsors for setting up the program and for checking boxes (literally – “we had a meeting with so-and-so”) to satisfy reporting requirements and subsequent payments. These dollars were permitted to flow to sponsoring organizations (most of them medical care systems) in advance of any true performance expectations.  Indeed – the first ½ of DSRIP funding (so – billions of dollars) flowed to medical care systems in advance of any expectation of improved health or reduced preventable spending. The justification for this was often that there were anticipated losses of fee-for-service revenue – and that the medical providers needed to be made whole in advance of these anticipated losses.  As any economist will tell you – payment in advance of something to be done is not an incentive to cause that thing to be done.  It’s a handout.  Indeed – a disincentive!  By half-time of DSRIP – performance started to be the objective – and PPS had to choose whether to be effective or not.  In several cases (yes – I have personal knowledge of these) PPS leaders who wanted to do very well on performance (therefore undermining the fee-for-service revenue of their parent organizations) were let go.  Yes. This happened. (No – not to me!) The medical systems didn’t really want to change.  They fired PPS leaders who did – as a product of rather simple economic decisions.  Performance would net them $x from DSRIP, but maintained and maximized fee-for-service revenue would net them $x+$y.  Done.  Did this happen everywhere?  No. This was a minority of PPS. But it happened.
  1. Too few.
    1. Too few outcome objectives. By focusing on medical definitions of success (generally expressed as HEDIS measures), the program medicalized social problems and failed to explicitly recognize the significant role that social determinants play in the health of our communities.
    2. Too few governing organizations.  By permitting (encouraging?) the majority of PPS to be governed by medical care providers, the foxes were guarding the chicken coops.  Our organization was an outlier – in that the governing organizations permitted us – in conflict with their own interests – to act in a manner that aligned best with the health of the people we served.  This speaks to the integrity of our Board – maintaining their fiduciary duty to do what was best for the organization (and by extension the whole community) rather than (or – ok – in addition to) their own institutions. This was the case in a small minority of PPS – and even in ours – the tension was always there. As our Board will recall – we even bought hats at one point – to explicitly remind them to “wear their PPS hat” when making governance decisions.  It wasn’t easy.  Had PPS been required to have broader governance – including community-based organizations, health plans, faith-based organizations, Health Information Exchanges, and other nonprofits, we would have had more balanced governance decision-making that would have supported the policy goals of the program more consistently statewide.
    3. Too few dollars (going to the right places).  A core tenet of the program was that no more than 5% of the money could go to so-called non-safety-net providers.  The definition of safety-net providers explicitly excluded the true safety-net: most of the community-based organizations.  This structural flaw caused a cascade of funding challenges that (to this day) plague PPS successor organizations who do their best to get the dollars upstream – so they can prevent downstream cost and suffering.  

So with this too many/too few framework – let’s parse the Kotter Edition and see how we are doing.  I’ve cut/pasted selected sentences from the DOH document to make it easy to follow here – but (of course) the full document has more detail/explanation.  DOH prose has a blue background so you know what’s theirs and what’s my commentary.  Since you have already read the concept paper, (warning: pdf) feel free to scroll through the blue sections.

$17 billion over five (5) years to fund a new 1115 Waiver Demonstration that addresses the inextricably linked health disparities and systemic health care delivery issues that have been both highlighted and intensified by the COVID-19 pandemic.

Not a bad start.  They even separate “health” and “care” – (as they should)  👍

 Indeed, to address the full breadth of factors contributing to health disparities, NYS will not only pursue reforms and investment in the health care delivery system, but also in training, housing, job creation, and many other areas

Again – so far, so good.  The target includes upstream work. SDOH.  Cool.  Devil in the details .. How will this work?

Goal #1: Building a more resilient, flexible and integrated delivery system that reduces racial disparities, promotes health equity, and supports the delivery of social care.

1.1 Investments in Regional Planning through HEROs

HEROs, which will be mission-based organizations that build a coalition of MCOs, hospitals and health systems, community- based providers (including primary care providers), population health vehicles such as accountable care organizations (ACOs) and independent provider associations (IPAs), behavioral health networks, providers of long-term services and supports (LTSS) including those who serve individuals with I/DD, community-based organizations (CBOs) organized through social determinants of health networks (SDHNs, as described below), Qualified Entities (QEs) (which in New York are Health Information Exchanges (HIEs) and Regional Health Information Organizations (RHIOs)), consumer representatives, and other stakeholders.

HEROS may be led by a variety of existing and new corporate entities (e.g., LLC, not- for-profit) including but not limited to local departments of health or social services, behavioral health IPAs and other structures formed by regional participants. HEROs would assume a necessary regional planning focus in order to create collaborations, draw insights from different data sources and needs, and develop a range of VBP models or other targeted interventions suitable for the populations and needs of each region.

  1. Planning Responsibilities

The primary deliverable for HEROs is a Regional Plan:

  • Uniform Social Care Assessment.
  • Measure Selection and Development.
  • Targeted VBP Interventions.
  1. HEROs Governance

In each region, the NYS Department of Health (DOH) will contract with a HERO entity, which may be an existing entity or a new corporate entity formed by regional participants, including MCOs, primary care and other clinical and community-based providers, QEs, SDHNs and others. The HERO entity must establish a governing body representative of each constituent group and with balanced stakeholder decision-making authority, along with appropriate sub-committees composed of participants, to collaborate on developing and coordinating the HERO’s planning activities. With limited modifications to governance structure, some existing PPSs would be ideally situated to function as the HERO entity in a region. Moreover, local health departments could in some instances be well-equipped to serve as the regional HERO, as they already have some of the necessary data infrastructure in place, as well as relationships with other government entities participating in regional planning efforts around SDH needs, such as housing authorities.

  1. Sustainability

NYS anticipates HEROs would extend beyond the period of the waiver and become self-sustaining entities that continue to act as coordinating bodies, engaging in stakeholder convening activities and research and data analytics on regional health equity issues.

Feedback: As I’ll express below – I don’t think the HERO layer in the program is necessary at all – and its description includes a repeat of some DSRIP 1.0 aspirations of true community collaboration that are unfortunately impossible in these days of narrow clinical networks and cut-throat competition in the medical domain among both health systems and health insurance providers.  

We need a more pragmatic approach – and that means we scale back the dream that competing organizations will collaborate toward improved population health.  Without explicit programs that require value-based purchasing, it simply won’t happen.

Planning.  A seed fund for planning simply replicates much of what the PHIP was supposed to do – but never really did – largely because it was under-funded and had insufficient leverage.  

HERO, therefore, opens the door to the same challenges we had with DSRIP.  Since the release of the draft document – we’re already witnessing health systems and former PPS across the state – begin to quietly jockey for position here – even organizations that explicitly walked away from the DSRIP program when the well ran dry.  These should be obvious disqualifiers for any HERO hopefuls – or organizations that seek to participate meaningfully in the waiver. Did the PPS or its parent(s) flush the money to itself and shut things down? If so – noooo. You don’t get to play this time around.  You’ve explicitly demonstrated that you care more about institutional success than regional population health.  Actions speak louder than … well … anything.  

What I like about the idea behind the HERO is that there is one regional entity that’s accountable for population health.  Who is best suited for this?  To me – it’s obvious: government.  Indeed – the government is the only organization explicitly committed to serving in the public’s best interest.  The challenge here is that the state government doesn’t have the staffing, infrastructure, or bandwidth to engage regionally – nor should they.  Yet regional governments – county departments of health for example – lack the funding, staffing, and experience managing matters that the HERO is imagined to curate.  They’d need to staff up – and (alas) they are also subject to the regional political influence that the health systems have, and the proclivities of county executives. I’d not be confident that the counties could manage this seamlessly. New York City is an entirely different game – and I expect that the NYC Department of Health could manage such responsibilities – but there’s only one of these in the state.  Perhaps – under NYC DOH’s strong supervision (a majority of Board votes?) – HERO could work in New York City.  Elsewhere?  No.  It’s too much (governance diversity) and too much (fiscal responsibility) to be managed apolitically.  Those with political power will retain it, and true public health decisions will be elusive.  

More on what I think will work North of Yonkers after we consider the SDHN…

Investments in Social Determinant of Health Networks (SDHNs) Development and Performance

I’m tickled that DOH recognized Alliance:

Examples of these developing SDHNs include the Healthy Alliance Independent Practice Association (IPA), which described itself as “the first IPA in the nation entirely devoted to addressing social determinants of health;”15 the EngageWell IPA, which “was created by New York City not-for-profit organizations working together to offer coordinated, integrated treatment options that include addressing social determinants of health—housing, nutrition, economic security;”16 and SOMOS Innovation “a full implementation of the holistic care model” and “the next step on the path to culturally competent Value-Based [H]ealthcare.”

So what is it?

Each SDHN would consist of a network of CBOs within each region of the State (which should overlap with the regions and sub-regions that align with HERO development) to provide evidence-based interventions that address a range of SDH. The State would designate regions and select a lead applicant within each region, which may be a CBO itself or a network entity (e.g., an IPA) composed of CBOs. As mentioned above, a SDHN could also be a PPS (or a component of a PPS) that seeks to convert, or have already begun to transition, into a network entity focused on SDH.

The SDHN in each region would be responsible for: 1) formally organizing CBOs to perform SDH interventions; 2) coordinating a regional referral network with multiple CBOs, health systems and other health care providers; 3) creating a single point of contracting for SDH arrangements; and 4) screening Medicaid enrollees for the key SDH social care issues and make appropriate referrals based on need. The SDHNs can also provide support to CBOs around adopting and utilizing technology, service delivery integration, creating and adapting workflows, and other business practices, including billing and payment. These SDHNs will coordinate and work with providers in MCO networks to more holistically serve Medicaid patients, particularly those from marginalized communities, effectively wrapping a social services provider network with existing MCO clinical provider networks.

Exhibit 2: SDHN Structural and Funding Diagram

        Social Care Data Interoperability Exchange

The New York eHealth Collaborative (NYeC) and 2-1-1 New York have received funding from the HHS Administration for Community Living to establish a trust framework and statewide governance structure to support collaboration and exchange of community information across existing networks and users. NYS envisions that this platform would serve as the basis for the social care data exchange that regionally-based SDHNs will use across the state, and would be aligned with national standards as they develop.

Well – this is valid but omits some important components of this initiative.  As one who has worked very closely with ACL, ONC, and CMS, (and I chair the HIMSS SDOH Committee, where National work is being done to converge SDOH infrastructure) – I’ll remind /inform readers that ACL didn’t just award funding to NYeC for this.  They converged three applications into one – and the NYeC / 2-1-1 project is just part of a unified project for New York that also includes Northwell/NowPow and Alliance/ Unite Us.  I’m a bit confused by the (intentional?) exclusion of the other two equal partners in this project.  It’s a good project, but I’m feeling a bit Rodney Dangerfield here, and – for the record – this project wasn’t selected as a Phase 2 winner.

Shared Learning and Sustainability

The State will leverage the learnings from the SDHNs in order to support the integration of high-value services into managed care contracts and VBP arrangements on an ongoing basis that extend beyond the life of the waiver. While there is ample evidence around the potential for SDH inventions to improve health, advance health equity and better manage health care costs, the research around the effectiveness of scaling the interventions to a regional and statewide basis has not been measured.

NYS anticipates that the demonstration evaluation would examine this question, in order to leverage findings for long term policy changes in NYS, as well as other states.

Well – yes and this is the core responsibility of the SDHN: to invest where investment is appropriate and not invest where it’s not.  Since I’m occasionally accused of being anti-academic, I’ll give my detractors more fodder:  I don’t think research is appropriate or necessary.  This can be done faster with rapid feedback loops of interventions and measurements.  Maybe this is just semantics – but the term “research” invokes years of study and papers written in academic journals.  We need front-line, agile program definition, rapid-cycle outcome analysis and the ability to change course when the evidence directs us.  My sense from the narrative is that DOH imagines that this work will be easier and harder:  easier to define initial projects – and harder to know if they work.  I disagree with both.  SDHNs will make mistakes; they’ll make investments in programs that result in few positive outcomes, and they’ll invest in programs that result in fantastic outcomes.  The program therefore needs to allow for (expect) such mistakes as positive steps toward long-term success.  Indeed – one measure of early success could be that there were failures!  Too few, and we know that SDHNs haven’t taken enough risks.  Too many – and – well we need to learn more/faster.  Healthy Alliance IPA has been doing precisely this work for five years.  Perfect?  No way.  Getting closer?  Yep.  Learning every day.  But there’s a big missing part.  Read on.

Investments in Advanced VBP Models that Fund the Coordination and Delivery of Social Care via an Equitable, Integrated Health and Social Care Delivery System

With the HERO and SDHN infrastructure established, advanced VBP arrangements will support the mid-to long-term transformation and integration of the entire NYS health care and social care delivery system by funding the services needed to address SDH at scale.

Incentive awards would be made available to MCOs (that have participated meaningfully in HEROs) providers and organizations in qualifying VBP contracts approved by DOH. MCOs would be required to engage in VBP contracts with an appropriately constructed network of providers for the population-specific VBP arrangement.

The VBP funds through this waiver proposal would encourage the evolution of the MCO- network entity agreements into more sophisticated VBP contracting arrangements that incorporate health equity design, fund the integration with social care, adjust risk to reflect both the health care and social care needs of their members, reward providers’ improvements in traditional health outcome measures as well as advanced or stratified health equity measures informed by the HERO, and/or use fully prepaid payment models that fortify against fluctuations in utilization based on pandemics. In particular, using socially risk adjusted payment—whether through accurate use of z-codes or the data collected from the uniform social care assessment tool described above—can incentivize and appropriately reward plans and providers for caring more holistically for these vulnerable populations.  Prepayment approaches would also be available to providers who are not the lead VBP contractor but are providing care to the lead contractor’s attributed members through a downstream targeted or bundled arrangement.

Additionally, this component of the waiver would seek specific authorities for NYS to utilize global prepayment payment models in selected regions where these arrangements logically apply; that is, where there is a lead or dominant health system or financially integrated provider-based organizations with demonstrated ability to manage the care of targeted populations in that region. In a global model, the lead health system VBP entity—whether part of an integrated delivery system or clinically and financially integrated IPA or ACO—would extend successes and performance across payor types, including Medicaid fee-for-service (FFS), Medicaid managed care, Medicare FFS, Medicare Advantage, and/or commercial plans.

Well .. there’s quite a bit to this part, which is the problem.  The foundation here is the SDHN and the HERO, and now – as with DSRIP 1 – DOH wants to bolt on the health plans (rather than incorporating them meaningfully in the foundation) – requiring them to craft VBP arrangements that may be tied to the HERO and/or the SDHN.

Confused? Yeh – me too.  It’s a bowl of policy spaghetti – and the drum solo at the end is regional global prepayment – a thinly veiled effort to re-boot the NCIP – which failed to get community support (or CMS support) and died.

Let’s simplify.  We have to start at the beginning.

  1. Regional Governance  
    1. In very dense areas, with highly capable local government – HERO may fit.  This is the case in NYC and perhaps a few counties just beyond NYC.  Make the government (which is explicitly accountable to the taxpayer) the majority governance authority – and allow that entity to rapidly define health needs and regional priorities.  Minimal (if any) planning dollars should be allocated.  Get to work.  Pay for outcomes, not planning, convening, gathering, establishing or any other gerund.  
    2. In “rest of state” (as those of us beyond NYC are sometimes referred to) – there is no need for the HERO – as we’ll see below.  County governments – the primary organizations responsible for public health – should receive funding to enhance their human and technical resources – connecting them tightly to the SDHNs and HIEs in their regions – adding epidemiologists, informaticists, and program managers who can help connect regional policies to SDHNs, health systems, health plans, and CBOs. What do we call this?  The GRHEO (pronounced “GREE-OH”) – the Government Regional Health Equity Organization. GRHEOs will require (much) less funding than the HERO defines – and will have less responsibility – focusing only on need definition and coordination of county health and prevention services with SDHN and HIE/QE activities.  There should be no funding for planning – nor an attempt to govern regional VBP or SDHN activities.  These activities can/must be self-governing or they will be neither sustainable nor agile.
  1. SDHNs
    1. The SDHNs should receive zero funding directly from DOH.  Yes.  Zero.  Rather, the SDHNs should receive 2.5% of premium dollars for each attributed member from all MCOs that serve the SDHN’s region – and each of these dollars should be matched by the waiver for the initial three years of the waiver (flowing through the MCO) – falling to 1% for year 3 and 0.5% for year 4 so that by year 5, the programs will have demonstrated clear return-on-investment to the MCOs and they will be expected to maintain 2.5% PMPY contribution to the SDHN ad infinitum, so long as the SDHN performs well. This puts the MCOs right in the mix – where they should be. They are the benefactors of improved health, and the (secondary) victims of persistent fee-for-service.  By passing SDHN dollars through the MCOs, DOH aligns their goals with the goals of the SDHN and leverages the SDHN as a trusted broker rather than the passive recipient of funding from the state.  The SDHN will have the autonomy – in collaboration with regional government leaders – to select initiatives for investment, primarily by collaborating with CBOs to provide essential services that address SDOH.
    2. It’s essential to understand that SDHNs – by aggregating health plan SDOH investments regionally – will eliminate many of the inefficiencies that exist today, primarily caused by well-intentioned siloed efforts wherein health plans make SDOH investments that are disconnected from each other – and only apply to their own members.  For example, one MCO might invest in food, and another in housing.  Now – depending on the color of an individual’s insurance card, they can get either food or housing but not both.  Yes – I’m over-simplifying, but these problems – expressed well  here – can only be truly solved by a convergence of fiscal resources so that they can be rationally apportioned for all. 

Redesign the VBP Roadmap to Address Health Equity and Regional SDH NeedsNYS will develop a comprehensive range of VBP arrangements for the HEROs, SDHNs, and MCOs to consider adopting based on the specific populations and needs within each region.

OK .. details matter.  We’ll see how this flows.

Advanced VBP Contract Requirements and Funds Flow

The provider agreement entered into by the MCO and VBP network entity would need to implement or build on HERO programs with a specific emphasis on prepaid or global payment models, and address local needs based on priorities identified by the HERO. NYS envisions that not every VBP arrangement will utilize SDHNs as the vehicle for CBO contracting, especially in areas where there is a strong cohort of existing CBOs or IPAs that are already successfully managing the needs of specific populations. However, under the waiver, NYS would give funding preference to arrangements that utilize SDHNs.

Well, this seems awfully complicated.  Again – without the HERO, and with direct $$ from MCO to the SDHN (and of course by extension the CBOs) incentives should align perfectly – eliminating the need to prefer organizations that use the SDHN.  Medical providers would be  crazy not to participate with SDHNs – and health plans can further motivate them.  We don’t need DOH or HEROs trying to pick and choose.  VBP will happen if (and only if) DOH (and by extension CMS) makes fee-for-service hurt enough.  As Adam Boehler said a few years ago when he was Director of CMMI:  “I’ve never seen ‘no downside’ work.”  Let’s heed Adam’s advice.  A pinch of downside risk and this whole thing falls into place.  Keep tiptoeing around?  We’ll get the same “we’re trying, it’s so hard” excuses.

        Leverage Ongoing Primary Care Investments

While moving to health equity-focused and advanced VBP contracts, these models will continue to recognize the important role primary care plays in care management and service coordination. The role of primary care is evidenced by the significant investments that have been and are continuing to be made through the New York State Patient-Centered Medical Home (PCMH) program.

Well, if we’re being evidence-based, let’s carefully consider whether PCMH has really gotten us very far.  Most of the principles of PCMH are table-stakes in 2021.  It’s a program that’s been around over fifty years.  There’s nothing progressive about PCMH anymore – let’s not pretend there is.   Primary care – with downside risk, level 3 contracts, and high-bars for quality?  Yes! That’s progressive.  Plans and providers should receive compelling PMPM adjuncts for increasing levels of risk – making primary care providers engaged participants in understanding and reducing unnecessary acute care episodes, unnecessary medications, diagnostics, and therapeutics.  

        Capacity Building and Training to Achieve Health Equity Goals

Workforce and training are critical foundations to achieving the health equity goals under this proposal and to developing delivery systems of “well care” capable of serving the whole-person. To provide the SDH interventions through the SDHNs, NYS will need to expand the number of community health workers, care navigators and peer support workers, particularly drawing from low-income and underserved communities to ensure the workforce reflects the community they serve. Workforce training will also support regional collaboration under the HEROs, the SDHNs, and the move to advanced VBP models.

Yes – and all of this can be managed through the funds-flow model(s) I define above rather than through an intricate – over-designed (and likely too-prescriptive) model defined and enforced by DOH and or a HERO.  With the right incentive structure, the MCOs, the primary care providers, and the SDHNs can make the workforce investments.  If there are jobs, the training programs will occur, and with sufficient funding, the SDHNs can (as PPS did in the past) collaborate with community colleges to create training and/or certificate programs.  Why SDHNs and not MCOs or GRHEO?  Because the MCOs only rarely collaborate (so training would be siloed) and GRHEO would be too slow to respond to workforce needs.  It has to be the agile, committed SDHNs that would lead this work.  Input from others?  Yes.  

Ensuring Access for Criminal Justice-Involved Populations

Based on historical data in New York, approximately 83 percent of incarcerated individuals are in need of substance use disorder treatment upon release.  Meanwhile, the share of individuals in New York City’s jails who have mental illnesses has reached nearly 40 percent in recent years, even as the total number of incarcerated individuals has decreased.  Incarcerated individuals with serious health and behavioral conditions use costly Medicaid services, such as inpatient hospital stays, psychiatric admissions, and emergency department visits for drug overdoses at a high rate in the weeks and months immediately after release. This population can then be more effectively served as part of the health equity-informed VBP arrangements described above. With this purpose in mind, NYS seeks approval for the following eligibility changes:

Reinstate Medicaid Eligibility and Enroll Incarcerated Individuals 30 Days Prior to Release

Therapeutic Residential Treatment Pilot

While I agree – this section begins the “kitchen sink” part of the waiver draft.  Nothing is bad here – but I wonder if these could be folded into the above narrative to allow regions to address these issues with sufficient clarity and sensitivity to local needs.  

Goal #2: Developing Supportive Housing and Alternatives to Institutions for the Long-Term Care Population

Overall, the initiative has shown a reduction in the number of emergency department visits and inpatient hospital stays. On average, Medicaid claim costs declined by about $6,800 per person with high utilizers of the programs having an average savings of $45,600. Programs that transitioned individuals from nursing home settings saved an average of $67,255 the first year and $90,239 the second year in housing.


NYS seeks to extend this effort through additional supportive housing programming, which the State expects will be necessary to address downstream effects of the COVID-19 pandemic, such as additional instability in housing for many Medicaid-eligible individuals and families and an urgent need for supportive housing for people experiencing homelessness.


  1. Investing in Home and Community-Based Services as Alternatives to Institutional Settings

  1. Local & Statewide Planning & Coordination through HEROs

This coordinated approach to housing will utilize HEROs outlined in the earlier section, as we anticipate housing to be a universal need. HEROs would conduct an inventory of supportive housing programs in each region and identify the gaps that exist, mapping existing efforts and any gaps by area and vulnerable population.

  1. Statewide Housing and Home-Based Services Initiative

Through this waiver, the State will establish a Statewide Housing and Home-Based Services initiative to consolidate and expand its array of supportive housing and medical respite programs. This initiative will be coordinated across state agencies and result in the development of a comprehensive and unified supportive housing and respite services menu. The services provided could include, among others

  • Medical respite models of care for post-hospitalization discharges and transitional housing;
  • Case management and care coordination, including tenancy assistance, rental assistance, transitional support services, and referrals and linkages to care;
  • Behavioral health supports, including substance use disorder services;
  • Environmental supports and accessibility modifications;
  • Employment and vocational services; and
  • Additional SSI state supplemental funding for high needs populations.

NYS will also reach out to community partners to solicit additional and innovative ideas for new types of services that can be piloted and tested for their ability to enact long-term improvements.

Again – this is another example of DOH separating an initiative that should be converged.  Housing insecurity is a social determinant of health.  A simpler approach here is therefore warranted, leveraging the 2.5% PMPM payment from the MCO to the SDHN.  Regional needs assessment would be performed by the GRHEO and the SDHN, with investments made by the SDHN where indicated.  So – yes – we agree completely that DOH and other agencies should coordinate well here – but this shouldn’t be a separate narrative, funding stream, accountability cascade, or governance matter.  Keep it simple.  

Specific Supports for Individuals with Behavioral Health and Substance Use Disorder Needs

  • Enroll eligible individuals in Medicaid 30 days prior to discharge from a correctional facility
  • Authorize Medicaid reimbursement for Critical Time Interventions models to help people transition across levels of care
  • Expand available services to support reintegration into the community

Yes. This all makes sense – but (again) why create a new silo here?  Make reintegration an element of the SDHN’s commitment to DOH and the MCOs.  Done.  How this gets done will vary by region, because the challenges and available resources (or lack thereof) of reintegration vary by region.  

Goal #3: Redesign and Strengthen Health and Behavioral Health System Capabilities to Provide Optimal Response to Future Pandemics & Natural Disasters

Although this waiver demonstration’s primary focus is to address disparities in access to quality health care and social care and achieve an equitable pandemic recovery, the COVID-19 pandemic also revealed that NYS must have a ready-to-execute strategy to respond to a significant increase in demand for acute care services. This includes a greater volume of hospitalizations, higher intensity of care services, and the need to replace disrupted acute and chronic healthcare services that are attributable to a pandemic. Redesigning the healthcare delivery system to efficiently achieve better outcomes in underserved areas during non- emergency times must be done in a manner that also supports rapid mobilization of resources for pandemic response demands on hospital capacity, workforce, supplies and continuation of essential healthcare services and quality care during an ongoing crisis.

(Sigh – note that this section was clearly written by a different team – as they use “healthcare” rather than “health care.” As noted above, the latter is correct.

Pandemic Response Redesign

  1. Physical and IT Infrastructure Preparation and Planning

  2. Inventory Planning

  3. Training in Order to Respond to Needs and Minimize Disruption to Delivery of Needed Healthcare Services

Develop a Strong, Representative and Well-Trained Workforce

Even prior to the COVID-19 pandemic, areas of NYS were experiencing workforce shortages across the health care continuum. Building on the work from the prior waiver demonstration that ended in March 2020, proposes a substantial reinvestment in Workforce Investment Organizations (WIOs) to focus on the needs of their respective regions and coordinate with the other WIOs across NYS to facilitate a cohesive approach to workforce development and share best practices. Planning efforts will involve a variety of stakeholders, including government entities, labor organization, provider organizations (inclusive of former PPSs with proven workforce strategies), and CBOs. Importantly, this investment would both expand capacity through a well-trained and culturally informed workforce and recognize that training investments themselves function as an important SDH, related to job insecurity and unemployment. Funds would support initiatives targeted at addressing workforce needs and the specific projects outlined for this waiver demonstration, and would include:

  1. Recruitment and Retention Initiatives

  2. Develop and Strengthen Career Pathways

  3. Training Initiatives

  4. Expanding the Community Health Worker and Related Workforce

  5. Standardize Occupations and Job Training

The workforce components of the waiver draft all seem appropriate elements of the right strategy and yet – gosh – I can’t quite put my finger on it – how we get this all done may (or may not) be through the methods expressed in the draft.  For example – I’ve already mentioned above that Community Health Worker expansion may happen organically when(if) SDHN/MCO investment in this domain grows.  But we know well that one size doesn’t fit all, and it’s possible that Community Health Workers aren’t what a given market needs.  Market forces will be more sustainable – both for expansion and (if necessary) standardization.  Several communities attempted both (g) and (h) above through DSRIP, with suboptimal results.  This part of the waiver proposal should be re-expressed as a strategic goal – with SDHNs and MCOs collaborating with GHEROs to define roles and then hire the people – eliminating much of the up-front cost and delay of funded planning activities.  As I’ve said above – pay for outcomes and expect regional work to define and implement the right programs.  If the methods are defined in some office (or home office) of DOH staff, and negotiated with CMS staff, we’ll propagate waste and miss the opportunity for efficiency and truly effective programs.

And here we are – finally – something in my wheelhouse.  For readers who haven’t tracked my career – I’ve worked in health IT for nearly 30 years – and (yes) I agree wholeheartedly that robust IT is an essential part of a healthy New York.  

Goal #4: Creating Statewide Digital Health and Telehealth Infrastructure

A silver lining of the COVID-19 pandemic has been the opportunity for—and accelerated realization of—widespread consumer and provider use of digital and telehealth care, including tools such as remote patient monitoring, innovative care management technologies, and predictive analytics. Consumers report high satisfaction with telehealth options, with prominent surveys showing satisfaction levels of 86-97%, often higher than for in-person visits. 

The State will therefore use waiver funding to create an Equitable Virtual Care Access Fund to assist such providers with these human capital investments, resources, and support.

Significant additional planning and investment is critical to create a robust infrastructure for telehealth, telephonic, virtual and digital healthcare. Through a statewide collaborative group, the State will identify local strategies/solutions for mutual assistance and to also inform statewide standardization of technical requirements, workflows, as well as training and technical assistance to further build the necessary infrastructure to meet the immediate and long-term needs.

The details expressed in this section outline the many advantages of telehealth, e-consults, etc.  The Equitable Virtual Care Access Fund would assist medical, behavioral health, and (presumably) other parts of the safety-net such as CBOs, to invest in the human and technical infrastructure so that telehealth becomes a “new normal.”  Yes. But once again, the DOH proposal involves quite a bit of planning and rather little trust in the entities that would (see above) have been empowered to address these issues and in fact have already done this.  We’ve seen this movie before: in 2009, the HITECH Act, part of the American Reinvestment and Recovery Act, funded incentive money for medical providers and hospitals to invest in information technology.  The program(s) – often described as the “Meaningful Use Incentive Programs” – or “MU,” provided incentive dollars for medical providers who made meaningful use of certified EHR technology.  The plan was that there would be three stages:  1) Adoption, 2) Connection (interoperability), and 3) Improvement. I was an HHS leader for three years during the heart of these programs, and therefore learned a great deal about how (and how not) to implement policies to accelerate adoption of new technology and new ways of providing health services.  Stage 1 worked incredibly well.  With the help of Regional Extension Centers (RECs) – thousands of practices selected, purchased, implemented, and optimized information technology.  The goals of the stage were clear and yet sufficiently flexible.  (Stages 2 and 3 were much more difficult for reasons we’ll not go into now.)

So if the goal is to provide support for service providers to implement and optimize telehealth – why not emulate what worked in the past?  Let’s sidestep the potholes on this road ahead, limit “planning” and statewide committees – and use a framework that will get us there without building from scratch and learning the lessons learned before:  simply create explicit, simple methods for organizations to apply for Equitable Virtual Care Access Fund assistance for:

  1. Selection and implementation of telehealth tools
  2. Service provider training and optimization
  3. Ongoing Software-as-a-service fees

During the pandemic, Healthy Alliance IPA supported many CBOs and behavioral health providers in the transition to telehealth by purchasing licenses to secure video conference services and donating laptops where necessary.  This isn’t difficult.  The tools (as any pandemic-era 6th grade student can confirm) are now commodities and after some early security hurdles – are secure, reliable, and ubiquitous. Let’s just do it.

I do see a bit of telehealth myopia here and wonder if there aren’t additional opportunities to assist CBOs and behavioral health providers in the procurement and implementation of functional health information technology. (These folks were left out of the federal incentive programs.)  Products offered to these organizations are often not aligned with the ONC Standards and Certification regulatory framework and therefore these organizations can’t participate with health information exchange (the verb, not the noun) as can medical providers and others who participated in “MU” back in the day.  Within the allocation to the SDHNs – these organizations could request funding for health information technology to support day-to-day operations, and such funding could be tied to implementation of only products that meet the ONC’s ISA. By invoking a federal standards framework, DOH sidesteps the work required to define and enforce criteria, and aligns New York with HHS priorities and objectives.  This is self-evident  (to me) yet absent from the draft proposal.


The 2021 1115 Waiver proposal from New York DOH describes an ambitious agenda that does improve on the DSRIP program that was implemented from 2015 – 2020.  How does it fare in the context of our “too many, too few” evaluation framework?  

Too many.  

    1. Too many organizations.  Too many targets.  
    2. ✅ If we can compress (or eliminate) the HERO – and have very few SDHNs – I think we can check the fist box easily. SDHNs need geographic scale to be effective.  Healthy Alliance IPA has been working – through partnerships – in three markets (Capital Region, Adirondacks, and Central New York) and this has worked quite well – making infrastructure investments more feasible and spread over a broader service area, while maintaining “local flavor” of CBO interactions and service optimization
    3. ✅ Again – devil in the details, but if SDHNs – in collaboration with MCOs – in a true “trusted broker” model – can define measures of success autonomously – this will work well.  The draft proposal does recognize the limitations of medical measures of success (HEDIS and others). 
  1. Too many choices.  
    1. ✅ By avoiding the mistakes of DSRIP – this program avoids the laundry list of tactical programs and would allow regional efforts to define and then focus on what’s important.
    2. 🟨 Too many dollars (going to the wrong places).  We’ll have to see.  The HERO model concerns me – and if left as-is, there is simply too much responsibility put in its hands – with high risk of misalignment with true public health priorities.  With modifications of the HERO model as I express above – and funds flow from DOH ⇒ MCO ⇒ SDHN, we solve this. ✅

Too few.

  1. Too few outcome objectives.
    1. 🟨 I don’t see any clear outcome objectives and this concerns me – as does the frequency with which “planning” is mentioned as a solution to our problems.  Some strategic planning is always necessary – but as a step 1 toward implementation.  The outcomes here that we seek are clear and achievable: All New Yorkers are healthy and happy.  How do we measure this?  We may be ignoring an easy method:  just ask.
    2. 🟨 Too few  governing organizations.  
      1. We’ll see what happens.  I’m optimistic that DOH understands what happened and won’t repeat it – but the structure of the HERO could very well replicate flaws of the previous iteration.  My GHERO idea – putting local government in control will be a big step in the direction of fixing this – though I do have a nagging concern that politics could still interfere. We have certainly seen this with Covid-19, where elected county leaders made decisions that were in conflict with public health objectives. We will therefore need a way to protect county public health leaders from political consequences – protecting them and making them accountable to DOH.
      2. Too few dollars (going to the right places).  
        ✅ “Safety Net” is mentioned several times, but it’s still not clear if this means what it meant for DSRIP.  If so, we have a problem.  If we can expand the definition – so we don’t have the 5% problem that we had before – we’re good here.  I’ll be optimistic.

So there we have it.   It’s a great effort and I suspect that the work is the product of quite a bit of political needle-threading for our colleagues @ DOH.  Hopefully, we can sand off the edges, collaborate well with CMS, and get this thing kicked off ASAP.  

Parsing Volume to Value, Proxy Measures, and the Streetlight Effect

Despite some concern that the migration from fee-for-service to value based payment (VBP) is being reversed, there remains strong momentum for VBP – both nationally – in the form of the bipartisan 21st Century Cures Act that was passed and signed into law last December, and many state and commercial initiatives, including the one I’m personally involved with, New York Delivery System Reform Incentive Payment Program (DSRIP). Defining value, of course, is not easy. I’ve often returned to Michael Porter’s short essay on this topic when I feel my definition meandering. Go read it now. Please.

Ok, you’re back? Cool. That was good, eh? I love the last paragraph:

The failure to prioritize value improvement in health care delivery and to measure value has slowed innovation, led to ill-advised cost containment, and encouraged micromanagement of physicians’ practices, which imposes substantial costs of its own. Measuring value will also permit reform of the reimbursement system so that it rewards value by providing bundled payments covering the full care cycle or, for chronic conditions, covering periods of a year or more. Aligning reimbursement with value in this way rewards providers for efficiency in achieving good outcomes while creating accountability for substandard care.

As CEO of Alliance for Better Health, I’ve been working with care delivery organizations in our community to navigate the path forward. They clearly have their feet in two canoes: the majority of their reimbursement continues to come from traditional sources with a traditional structure: more patients seen = more money. And then – from the edges, they have people like me telling them that the future is something different. It’s new, it’s going to pay them to do something that they would like to do – but they’re not quite sure how to do it, and, yes, some fear accountability.

Walk before we run, or jump right into the deep end? How do we traverse this gap between where we are and where we would like to be? One framework says that here is no traverse at all: we need to leapfrog to tomorrow and start from scratch. Iora Health is one such model. Care providers are focused on personalized, proactive care. The practice is led by health coaches, nurses, physicians, and administrators working together as teams to maximize health for the communities they serve. Reduced cost is a byproduct of great care, not a target itself. The office workflow is different from a traditional practice, the architecture is different, the hiring practices are different, the EHR is different. This model steps out of the old canoe and into the new one. For those with the guts, it’s a great model. For the rest, a slower path may work better. Of the slower paths, there are a handful of options, and many of them are complimentary rather than mutually exclusive. Accountable Care Organizations represent a compelling alternative to the Iora-style leapfrog. By offering a migration path – with increasing levels of shared risk, an ACO can coalesce a community of providers, collaborate with the federal government or commercial payers to standardize care for the better, and improve health outcomes. There are many models of ACOs, but I would argue that a common thread for the successful ones is that they have maintained laser focus on two guiding principles: a) success will attract the right partners; b) great primary care is the keystone of an ACO. Let’s parse this for a moment: why do I say that success will attract the right partners? There is a misconception that one should start with the creation of a large ACO. Growing the numbers of care delivery organizations will grow the number of “accountable lives” (people) and therefore, if one follows the “bigger is better” hypothesis, one can take advantage of the scale to reduce overall risk, and create a more powerful negotiating lever with the payers. While seductive, this hypothesis is flawed. A big network is hard to manage, and an ACO will be forever “herding cats” if they start too big. They won’t see shared savings, and they won’t be able to meaningfully accept risk, because they can’t be confident that they will perform well. An alternative model, and one that has been followed by all successful ACOs, (which, of course, includes my friends at Aledade) is to start small. For the first turn of the ACO wheel in a community, focus on a small group of providers who are “all-in.” They are fully engaged and dedicated to the success of the program. When successful, this attracts others – like moths to a light bulb – to the program. The ACO can then attract great partners (great primary care providers) rather than working hard to corral everyone and then re-educate them to the new ways. The difference, of course, is “pull” vs “push.” “Pull” usually works – and if it doesn’t, it wasn’t meant to. “Push” never does. We call this Motivational LeadershipTM (More on this in another blog post.)

DSRIP Performance. Many states have DSRIP programs, and it’s beyond the scope of my essay today to explain what DSRIP is, or what exactly New York’s variant represents. Today, our focus is on DSRIP Performance. Click on the image over there for a snapshot of what I mean. Each line is a measureAlliance Performance Measures and our performance against this measure will determine a payment from the New York Department of Health. The program (more than) pays for itself: with improved health of a population, unnecessary acute care services are prevented. Healthier people, better care experience, lower cost. In that order.  One challenge that we have is that the dependent variable here is our community’s performance, yet we won’t know what that is for 6-12 months .. which gets us to the heart of our story today: proxy measures and why we need them.

  1. Problem to solve: we want to pay our community for performance against DSRIP goals. Most of these goals of course are measures. We call them outcome measures but internally we know that most of them are process measures. That’s ok. It’s all a continuum. We’re not going to measure life expectancy (we don’t have 50 years)  so we?ll have to draw the line somewhere  and preventable ED visits? (and the 38 other measures you can see by clicking on that thumbnail above) may be just fine.
  2. Hurdle to leap: DSRIP funds have too long a payment lag. Telling a CBO or small practice or a hospital CFO that I’ll pay you Tuesday for a hamburger today (I’ll pay you in 2019 for preventing ED visits now) just won’t work.It’s too far. I can’t train my dog to sit by rewarding him in an hour. I need to tie the positive reinforcement to the act that I’m reinforcing.
  3. Opportunity: we?ve created an incentive program in which we have committed to distribute funds (which we have in the bank) in advance of performance. Up to 30% of the funds that could be earned this year will be distributed quarterly (up to 7.5% per quarter) for near-term performance.
  4. You are now asking the right (next) question:? How will you know what near term performance looks like? Aaahh .. yes! We will need to measure performance! In some cases (preventable ED visits) we will do our best to mirror DOH methods with the data that we have available from claims data, from clinical data feeds, and other sources that are available. Of course data we have available is a classic quality measurement challenge the so-called streetlight effect. We’ll avoid that as much as possible by using proxy measures.
  5. Proxy Measures are therefore a big topic of conversation in these parts. What’s a good one? What’s not? We want to let the community do some of this work as thinking about how to measure value is a great exercise for them as they transition to value based payment. We don?t need them to make these perfect!? That’s what I think is the elegance to this model. Worst case:? they make easy proxy measures that look like success, get 30% up front, miserably fail on the real? measures from DOH and we get $0 at the end. This is fine. We will have tried and they will have cheated? us for 30%. But we have the 30% this year to cover our experiment because of the evolution of New York DOH’s DSRIP program: this year, we still get some funding to support “pay for reporting.” Next year, we shift to nearly 100% “pay for performance” and $0 for “pay for reporting.” By allowing for this evolution, we encourage providers to experiment with proxy measures, allow them to be imperfect, all while pulling (not pushing!) forward into value based payment.  It’s unlikely that they’ll fail miserably and “cheat” us. Much more likely is that this enough to cause them to work really hard for true success. The 30% is then just a pre-payment  and they’ll get the 70% next year when it flows from DOH for our extraordinary performance.What’s an example of a proxy measure? Ideally, a proxy measure is a perfect reflection of the “real” measure we’re aiming to satisfy. So if we want to reduce preventable Emergency Department visits, and our performance measure will be “% annual reduction in preventable ED visits,” then a monthly (weekly? daily?) measure of this would be optimal. Indeed, if we had rapid insight, we could intervene. This where quality measurement, if performed real-time, actually becomes decision support. (This is a topic for another day …) So here’s an example of a less obvious but perfectly reasonable proxy measure: if we accept the hypothesis that preventable ED visits are a given percentage of all ED visits, and the hypothesis that ED visits resulting in hospital admissions are less likely to be preventable ED visits (they represent conditions that merit a hospital admission) then if the proportion of ED visits that result in hospital admissions grows, one might conclude that the number/proportion of preventable (unnecessary) visits fell.  Long-term, this would be a terrible performance measure, since it may cause the ED staff to feel pressure to admit more patients. But as a proxy for a reduced number of preventable ED visits, I think it does a nice job. Do you agree? Disagree?

You can play too, if you like. Here is an editable spreadsheet with all 39 of our measures. Add/edit columns with your ideas for proxies! You can also see much of the baseline data for the DSRIP performance measures (and others) by poking around here.

12 years of blogging .. about medicine, technology and their intersection …

This post from November 26th, 1999 – was the first on this blog.  There were a few months of previous posts, but due to several platform changes back then – these seem to be lost.  

No matter.  12 years is a long time.  My blog is now officially an adolescent.  I wonder what it will be when it grows up!  Long-time readers are of course observant that I've been remarkably quiet for the past few years.  This is due to my evolving work for an HIT vendor and now the Federal Government.  

So I've been operating with this in the background for the past six years:

The opinions expressed on this blog are my own and do not represent the veiws of my employer.

And there is a rough "social media policy" (google docs – you have edit rights .. feel free to steal or enhance … ) that I have in my head as well .. so in general I have done my best to observe and occasionally point to important publicly available information, but take care not to comment too deeply – for fear that others would interpret my commentary as a telegraph of my employer's next steps.  This wouldn't be appropriate for me to share – and increasingly – I am concerned that most of my public thoughts could be interpreted in this way – so I've been holding back from any public commentary.

So for now – here we are. 

I'll push the envelope a teensy bit and comment on some events of the past few months:

Tim HISTalk covered my arrival at ONC in a post about a month ago.    He asked the right questions about the topic at hand – but he didn't get to the one that I am hearing often these days – which is .. "Why did you leave your leadership role at one of the top health IT companies, choose to spend weekdays away from your family, AND (with two kids in college) take a giant pay cut?"  

The answer is easy:   It's the right thing to do.  

Health Care in the United States  is at a turning point.  It is well known that despite great advances – we don't provide the quality of care that we would.   It is also self-evident (to me) that technology – carefully applied – will improve both the quality of care – and the efficiency, sensitivity, and ease with which it is delivered.  Yes – some of those words may not be familiar to you – but why WOULDN'T we want it to be EASY to deliver great care?  Why shouldn't we deliver SENSITIVE care (sensitive to your hopes, religion, fears, preferences) – in addition to efficient, evidence-based and (of course) cost effective) care?

 So I have always tried to focus my work on helping others meet their true potential.   In my first career – as a 16 year old sailing teacher, I helped kids find the freedom and autonomy that a good breeze and a sunfish will provide.   As a teacher of junior high school kids – I witnessed breathtaking intellectual growth in a herd of 12 year olds who were otherwise distracted by adolescence and its daily challenges.  Working with (some say "caring for") patients as a family physician - I found that my most important work was not to take control and "fix" my patients (as some of my mentors had advised in medical school) but to partner with my patients – serving as a resource – without any judgment or critique.  As Bill Miller and James Prochaska have demonstrated (motivational interviewing, transtheoretical model) – people change when they choose to – and no sooner.  Can we facilitate growth in others?  Of course we can.  But "facilitate" and "cause" are inherently different.

As a leader in a large health IT software company – my role was often to help our teams align the software products we were producing with the needs of our customers.  This is not unlike the role of a good physician:  we need to listen carefully and critically so that we understand the needs (which will sometimes differ from the "wants") so that we can facilitate success.

And isn't that the role of government too?   Perhaps that's a political question.  Some would argue that government should get out of the way, while others would argue that there is an important role for government to provide an infrastructure with which success can be facilitated.  Is a healthy happy nation something that is important?  Are there ways that government can facilitate a migration toward these goals? 

I think so.  Keep an eye on my occasional tweets , g+ posts (rss), and posts here on this blog.  It will continue to be sparse here on the blog. 

Sammy Starts a Business …

With some help from Nikita – the offshore development leader, Sam is on the edge of releasing his first website.  While it's not likely to cause him to be the next Sergey Brin – he hopes to make a little bit of money – and provide a valuable service.  Details to follow in a few days when version 0.5 goes live …

Sam needed to create an LLC.  When we created Oncalls.com about a decade ago – we did a quick google search (maybe it was Altavista back then!) and chose a company that could "take care of creating a company for you" for a low-low price.

But the low-low price we paid got us stuff we didn't really need (a special seal, a binder with 10 pages in it, an annual fee for a Registered Agent, etc.

So this time – we used UpstartLegal.   They do what you need (help fill out the forms and file them with your State and with the IRS – and don't do what you don't need.  Most of the companies that you find on the Internet will charge you more for filing with your state – and they generally include registered agent fees.  But if you create your LLC in your home state – you don't need a registered agent.  So even though they may have a low-low price of $99 – when it all comes together – you'll end up paying much more than that .. and more every year thereafter.

The UpstartLegal team is smart, honest and very clear.  It's a nice service that made this part of Sam's new endeavor completely painless and worry-free.  Well done. 

Agile Development

The Agile Manifesto seems like ancient history now.  The concepts of iterative development were not new – but they hadn't been marketed until the manifesto was published and the movement was unleashed.

In  late 1999 or early 2000 I can remember sitting in a meeting room with the Assistant CIO of a large healthcare organization .. describing my preference for using what I then called an iterative development process – where we would define "bite-sized parts" for implementation, exposure, and refinement on a regular basis. 

She had never heard of such a thing – and advocated for the developers on the team: 

"They need to know when it's finished!" 

Me:  "This is software – it's never finished"

"But the customer needs to sign off on a completed project.  How can we know that it will meet the customer need?"

"uuuh … ask them?"

"We ask them during the requirements process – when they define the project"

"And that is successful?  They are always happy with the final product?"

"Well – no – but if they didn't describe their needs appropriately – that isn't our concern.  So long as they have signed off on the spec before the development work begins – we have clarity for the what the requrements are – and if we build it to spec – we've completed the project and we can move on."


I stopped trying.  Clearly the goal here was to complete the project "to spec" and move on to the next project. 

There was a problem though – developers were bypassing standard process – and interacting directly with customers (with no management oversight) and were creating solutions collaboratively with customers.

So the Ass(istant) CIO wanted to give the developers a sense of closure .. but the developers wanted to please the customers – and bypassed their managers to do so!

Trouble in them thar hills, too.  With no Human Factors training – and minimal design skill – developers all-too-often gave the customers what they asked for rather than what they needed.  End result: ACIO came down hard on such "renegade" developers.

This reinforced the waterfall mentality.  🙁

Writely Invites, Google Calendar SMS tricks

I noticed that Writely has just increased the number of invitations that current users have available. I'm curious. If you have one availabe .. please send me one (if you have my e-mail address) .. or if you don't have my e-mail address, you can use this form to send me a note and I'll reply with my e-mail address.

And Bruce sent me a link to this post about how to interact with google calendar via SMS. It works!

RFC3219 – for nerds only

The IANA RFC3219 listing shows who the real early adopters are in the SIP namespace.  Dorks who really want to call me will be able to dial my extension (yeh – right – like I'm going to publish that on the weblog!) at phonehost.slingerlands.com.  (No .. it's not really "phonehost" either)

See the ISN cookbook for more on this and how to get your own.



VOIP, SwitchVox, SSL

We are getting very close to the day that we go live with our new phone system at the office.  Still a few bugs to work through .. but I've had enough random requests for the status – ever since I posted my review of SwitchVox that I do owe a bit of an update.

Here goes

The software is good, and we've been getting help from the tech support staff at FourLoop throughout.  There remain some wrinkles here and there, but updates seem to be coming at a pretty good clip – so I expect things will continue to improve.  

What sort of rough edges?  Well – the features of the software have come along well since the publication of the manual in June – and the help system that is embedded in the software is good.  But the documentation hasn't kept up with the features of the product – and this is sometime frustrating. It takes a while to "get" the best method for creating a really good IVR – and I wish that there were examples of more complex IVRs in the documentation – especially how to use the "option" functions.  Here's how (I think) it works:  Create an IVR.  Have step 1 be "play a sound" such as:  "choose 1 for eggs and 2 for peanut butter."   Now choose "options" and tell SV where to go when the user chooses Option 1 or Option 2:

Yes – it really is easy-as-pie.  And I THINK this is the way I'm supposed to do it .. but nothing in the documentation leads me there.  Some of this makes perfect sense and is very powerful-yet-simple (an awfully challenging combination to create) but the simplicity gets the upper hand in some places of the IVR – especially where it comes to the handling of options – and the handling of conditional clauses.

Having "options" stuck at the bottom of an IVR means that they HAVE to be the last thing that a user encounters.   While it's possible to develop a complex IVR that sends the user right to the end .. and then based on the option chosen – back up to a step above – this gets confusing quickly.  It would be much more intuitive to have the "options" behave like any other IVR action – since they are really just a "case" statement.  

And speaking of logic – the conditional clause is GREAT .. except it's only part of what I'd expect to see in a conditional clause.  I want ELSE and OR and AND and ELSEIF.

Ok.. enough complaining.

Josh and his team built something that I LOVE – and it's easy to use too.  It's a URL that I can put into web applications that causes the system to do something.

Here's the documentation for how it works:


What is the Call API?
The Call API provides a web interface for originating calls through the PBX. This is often called click-to-dial, and is done by requesting a specially fomulated url from the pbx.

How does it work?
Below is an example URL and a description of its functionality.

Originating a call Example URL:
cmd=callTells the PBX this command is a call origination command
extension=104What extension to ring on the PBX system
When the call is answered by the extension this will be the number it will try to ring

How do my Call API Settings effect the call API?
The Call API settings allow the pbx to modify requested phone numbers so that they correctly match what the system expects. For example, if you request that the API dial 8005551212, the Call API Settings will add a 9 and a 1 to make the number 918005551212, which will then be dialed by your phone.

So if I have a link on a web page of our mini-EMR with a picture of a phone .. and it links to the pbx and tells it to call 5551212 from extension 500 .. then it calls 5551212 AND rings x 500 at the same time. So from the patient's chart – I can click to call the patient instead of dialing.
Yeh – you've heard of "click-to-dial" and you are not so excited?  maybe the fingers need a little exercise?
Ok .. but … say you need to call 1000 people over 4 days and let them know you have flu shots available and they can choose any of three saturday mornings to come in and get one.  How can you use the API to do THIS – you say?
Build a little application (I use coldfusion but you could use anything you like) .. and do the following:
  1. Build an IVR that plays a sound:  "Hi – you need a flu shot. If you want one – listen carefully.  You can come in and get one on any of the following days …  Press 1 for November 63rd, press 2 for October 34th and press 3 for December 44th. If you are hearing this message on your answering machine, you may call us back with your choice by calling 111-1111"
    1. Since the IVR will know who is called – it will send the result back to the application with:
      1. Name of person
      2. Date they chose
      3. (or that nothing was chosen – so maybe we got the answering machine .. which is fine.  We'll set up a temporary route on a DID so that when people call back they will get right to the IVR.  No waiting for a human.
  2. Query the database for the people you need to call and their phone numbers
  3. Loop through the query and send the phone numbers to the phone system every 40 seconds or so (evenings .. so we don't clog up the phones during the day).
  4. In the morning – run a report from the application to see who was called – who responded (and how) and how many people we need to schedule for the flu clinic on Saturday.
This works fine and I tested both the IVR and the Coldfusion and it seemed like they would work well – but I didn't (until tonight) try to tie them together.
When I did I got a mean error that Coldfusion couldn't connect to the PBX and all I got was a cryptic connection error.
So I had to do a little research and finally figured out that I had several problems.
  1. Fourloop build SwitchVox to use SSL when you are logged in as the administrator.
  2. To use the call API – you need to use SSL
  3. The SSL certificate is self-signed which is fine since it's OUR server and I think I trust myself. 
    1. But that's a little annoying because the browser complains that it doesn't have that certificate and that the name of the certificate (pbx) isn't the same as the name of the server. 
    2. But it's not so bad because I can click on the little alert .. or take the 29 seconds to install the certificate on my computer.
  4. But Coldfusion can't click the little box so I will have to install the certificate on the coldfusion server to make it happy.  Steven Erat shows us here how to do that.  .. ok .. now that wasn't so hard.  (or was it?)
    1. But it still won't work.  See the comments on Steven's page.  Several people got through step 1 only to learn that step 2 still stopped it from working:  "I was wondering if you know of a workaround for CFHTTP when posting to https:// where the certificate name on the SSL does not match the host name.

      When attempting this, I receive an Error Detail of I/O Exception: Name in certificate `www.domainname.com' does not match host name `xx.xx.xx.xx'"

      Hmm .. looks like I have the same problem.

But I figured out the solution!  Since I know that the certificate is called "pbx" and I now have it installed on the application server (which in this case is the client – SwitchVox is the server) .. still follow? .. I make an entry in the "hosts" file of the application server called pbx and point it to the IP address of SwitchVox.

Now I run my test page and my cell phone rings (every 40 seconds!) and it tells me I need a flu shot and the browser window of the debugging test page says:

ServerApache/2.0.48 (Fedora)


So we have solved the problem of coldfusion having trouble with SSL and reporting a connection error: I/O Exception: Name in certificate.   First, Install the certificate on the Colfusion server.  Next,  make a "hosts" entry to fool cf into thinking that the name of the remote server is the same as the name in the certificate.