The Changing Healthcare Environment: 1115 Waiver Implementation in Texas

1
The Changing Healthcare Environment1115 Waiver
Implementation in Texas

• Alliance for Healthcare Excellence
• Dr. Ron Anderson, M.D
• Sue Pickens, M.Ed.

2
1115 Waiver

• Waiver Goals
• Expand risk-based managed care statewide.
• Support the development and maintenance of a
  coordinated care delivery system.
• Improve outcomes while containing cost growth.
• Protect and leverage financing to improve and
  prepare the health care infrastructure to
  increase access to services.
• Transition to quality based payment systems in
  managed care and in hospital payments.
• Provide a mechanism for investments in delivery
  system reform including improved coordination in
  the current indigent care system in advance of
  health care reform.

3
1115 Waiver

• Waivers impact is state and local, rather than
  federal
• Works whether the healthcare reform law remains
  intact or not
• Milestones
• Expansion of primary care
• Behavioral health goals
• Specialty care access goals
• DSRIP and UC more than doubles the former UPL
  annual payment

4
1115 Waiver

• Under the waiver, additional new funds are
  distributed to hospitals through two pools
• Uncompensated Care (UC) Pool Costs of care
  provided to individuals who have no third party
  coverage for the services provided by hospitals
  or other providers (beginning in first year).
• Delivery System Reform Incentive Payments
  (DSRIP) Support coordinated care and quality
  improvements through Regional Healthcare
  Partnerships (RHPs) to transform care delivery
  systems (beginning in later waiver years).

5
Proposed RHP Map
6
1115 Waiver CMS Expectations

• CMS Expectations
• Planning process that demonstrates regional
  collaboration.
• Projects selected address community needs
  identified through a Community Needs Assessment
  (DFWCH)
• Projects selected are the most transformative for
  the region.
• RHP Plan includes projects that tie into four
  categories established y HHSC to demonstrate
  outcomes
• Infrastructure
• Innovation
• Quality
• Reporting

7
Uncompensated Care Pool

• Anchor Hospital (IGT Entity) Provides funds to
  HHSC for match
• Hospitals apply directly using a state designed
  tool to receive UC payments to include
• Physician costs related to direct patient care
  services
• Mid-level professional costs related to direct
  patient care services
• Pharmacy costs related to he Texas Vendor Drug
  program
• Excess Medicaid DSH costs not reimbursed via
  the Medicaid DHS program
• Specific tool for submitting reimbursement
  provided by HHSC through TexNet (not yet
  available)

8
DSRIP Pool Funding Flow
Reporting

• Public Hospital
• In areas with no public hospital
• Hospital District
• Hospital Authority
• County
• State University with HSC or medical school

Anchor RHP Administrative Functions
HHSC Approves performance
Performing Subcontractor Reports performance to
performing provider
Performing Provider Reports Performance
IGT Entity Reviews performance
Examples Examples Public Hospital Public
Hospital Public Hospital Private Hospital Public
Hospital Private Hospital Clinic LMHA LMHA

Funding Source
HHSC Requests IGT from IGT Entities
IGT Entity Provides IGT to the State
Payments
HHSC Requests federal match from CMS
CMS Approves Federal match and sends to HHSC
Performing Subcontractor Receives payments from
performing provider.
HHSC Provides payments to performing provider
Performing Provider Receives payments
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Texas Healthcare Transformation and Quality
Improvement ProgramSection 1115 Waiver
ProgramRegion 9 RHP Organization Ensuring
Regional Collaboration

• Anchors development of the Dallas RHP and the RHP
  Plan
• Develops the Dallas RHP Plan
• Designates Dallas Regional Healthcare Partners
  (Dallas RHPs)
• Performs a community needs assessment that serves
  as basis for the RHP plan
• Approves Dallas Intergovernmental Transfer (IGT)
  contributions
• Approves selected Dallas regional DSRIP projects
  from the State approved menu of projects
• Allocation of funds to UC and DSRIP projects
• Provides an opportunity for public input and
  review of the RHP Plan
• Provides ongoing Dallas RHP plan administration
  and reporting.

• Partner with DCHD to develop the Dallas RHP and
  RHP Plan
• Serve as a forum for the work group and task
  forces to develop required elements for the
  RHP/RHP plan.
• Assure range of Dallas stakeholders are involved
• Assist in project management and ensure project
  transparency
• Assist in coordinating Dallas input to DHHS on
  statewide elements of waiver program

Centers for Medicare and Medicaid Services (CMS)
Texas Health and Human Services Commission (HHSC)

• A work group designated by DMR and DCHD will
  serve as the project steering committee
  responsible for
• Developing recommendations to the DCHD Board of
  Managers on the Dallas Regional Healthcare
  Partners Plan

Dallas County Hospital District Board of Managers
(DCHD Dallas Anchor)
Dallas Medical Resource
Oversight Work Group Co-Chairs Tom Royer MD and
Joel Allison (Dr. Royer was replaced by Ted
Shaw)
Regional Healthcare Partnership (RHP)

• Develop Dallas Regional Health Partnerships Plan
  
• Designating Dallas Regional Healthcare Partners
• Community Needs assessment
• Identify and approve IGT contributions
• Approve selected Dallas regional DSRIP projects
• Approve allocation of funds to UC and DSRIP
  projects
• Provide opportunity for public Input and review
  of the RHP Plan
• Ongoing Dallas RHP Plan administration and
  reporting

1115 Waiver Steering Committee Tom Royer MD (Dr.
Royer replaced by Ted Shaw)
Uncompensated Care Pool Task Force Co-Chairs John
Dragovits and Fred Salvelsbergh (John Dragovits
replaced by Jody Springer)
Delivery System Redesign Incentive Pool Task
Force Co-Chairs Ron Anderson MD and David Ballard
MD
Committee replaced with the Plan Writing Committee
10
Texas Healthcare Transformation and Quality
Improvement ProgramSection 1115 Waiver
ProgramRegion 10 RHP Organization Ensuring
Regional Collaboration
Region 10 DRAFT Regional Healthcare Partnership
Planning Approach
Regional Healthcare Partnership Planning
Today (April 20 2012) 6 Month Year 1 Year 2 Year 3 Year 4 Year 5
April May June July August September October
Stakeholder engagement RHP Committee formation Centralized community Needs Assessment workshops Provide Community Needs Assessment templates, baseline data, guidance and technical assistance Provide DSRIP parameters, metrics and guidance per THHSC RHP (if allowed) Develop individual County Community Needs Assessments Conduct individual County Visioning Sessions DSRIP coordination, development evaluation process Develop RHP-wide Community Needs Assessment Begin RHP Plan Development Community forums for plan review Finalize DSRIP plans Draft plans to THHSC 8/1 Draft plans to CMS 8/31 Review/ update plans based on feedback Final plans to CMS
Regional Healthcare Partnership Committees Regional Healthcare Partnership Committees Regional Healthcare Partnership Committees Regional Healthcare Partnership Committees Regional Healthcare Partnership Committees
Elected Leaders County Judges other elected officials responsible for IGT entities Steering CEOs of Local Regional participant Hospitals, MHMR and School of Medicine Planning Planning officers of participant Hospitals, MHMR, Public Health and School of Medicine Finance (IGT and UC) Finance officers of participant Hospitals, MHMR and School of Medicine Quality/Clinical Quality/Medical officers of participant Hospitals, MHMR, Public Health, School of Medicine, Medical Associations
Regional Healthcare Partnership Collaborative Governance Guiding Principles Regional Healthcare Partnership Collaborative Governance Guiding Principles Regional Healthcare Partnership Collaborative Governance Guiding Principles Regional Healthcare Partnership Collaborative Governance Guiding Principles Regional Healthcare Partnership Collaborative Governance Guiding Principles
Transparency Patient-Centered Collaborative Value-Driven Accountability
Ensure that decision making process takes place in the public eye and that processes are clear to participants RHP and criteria should focus on improving patient care experience through more efficient, patient-centered and coordinated system RHP informed by collaborative process that reflects the needs of the community(s) in inputs of stakeholders RHP should focus on increasing value to patients, community, payers and other stakeholders. Better Care, Less Cost Stakeholders are held to common performance standards, deliverables and timelines
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Pool Funding DistributionTransformation is the
Goal
12
RHP Category 1 and 2 Minimum Number of Projects

• Four Tiers based on share of the statewide
  population under 200 percent of the federal
  poverty level (FPL)

Share of population under 200 FPL Min number of Cat 1 and 2 projects Min number of Cat. 2 projects
Tier 1 gt15 20 10
Tier 2 (Regions 9 and 10) 7-15 12 6
Tier 3 3-7 8 4
Tier 4 (Region 18) lt3, no public hospital, or public hospitals serve lt15 UC 4 1
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RHPs and DSRIP

• RHP Plans include
• Regional health assessments
• Participating local public entities
• Public engagement
• Identification of hospitals receiving incentives
  and of yearly performance measures
• Incentive projects by DSRIP categories
• RHPs and RHP plans do not
• Require four-year local funding commitments
• Determine health policy, Medicaid program policy,
  regional reimbursement, or managed care
  requirements

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Dallas Fort Worth Hospital Council Community
Needs Assessment Report. RHP 9 Findings
(DRAFT)

• The following regional priorities were identified
  as primary community health needs and are
  recommended for consideration as context for
  identification of strategies and recommended
  actions of the regional plan
• Capacity - Primary and Specialty Care
• The demand for primary and specialty care
  services exceeds that of available medical
  physicians in these areas, thus limiting
  healthcare access for many low level management
  or specialized treatment for prevalent health
  conditions.
• Behavioral Health - Adult, Pediatric and Jail
  Populations
• Behavioral health, either as a primary or
  secondary condition, accounts for substantial
  volume and costs for existing healthcare
  providers, and is often utilized at capacity,
  despite a substantial unmet need in the
  population.
• Chronic Disease - Adult and Pediatric
• Many individuals in North Texas suffer from
  chronic diseases that present earlier in life,
  are becoming more prevalent, and exhibit more
  severe complications.
• Patient Safety and Hospital Acquired Conditions
• Continued coordinated effort is needed to improve
  regional patient safety and quality.
• Emergency Department Usage and Readmissions
• Emergency departments are treating high volumes
  of patients with preventable conditions, or
  conditions that are suitable to be addressed in a
  primary care setting. Additionally, readmissions
  are higher than desired, particularly for those
  with severe chronic disease or behavioral health.

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Stakeholder Engagement

• Stakeholder Engagement
• RHP Participant Engagement
• Information for Performing Providers including
  hospitals, Community Mental Health Centers,
  Academic Health Science Centers and Local Health
  Departments.
• Public Engagement
• Processes used to solicit public input into RHP
  Plan and public review prior to plan submission,
  including county medical societies.
• Must include a description of public meetings and
  posting of RHP Plans for input.
• Plan for ongoing engagement with public
  stakeholders.

16
RHP Plans and CMS Expectations Regional
Transformation

• Transparent planning process that demonstrates
  regional collaboration and public input.
• Projects selected address community needs and
  regional goals.
• Projects selected are the most transformative for
  the region
• RHP Plan includes projects that tie to the four
  DSRIP categories together to demonstrate outcomes
• RHP Plan includes broad UC and DSRIP
  participation.

17
Funds Flow Mechanics DSRIP Pool
The allocation of the DSRIP Pool is quite complex
with respect to both the allocation to regions
and the allocations within each region
Percent of population lt 200 FPL Percent of Medicaid acute care payments Percent of UPL program payments Hospitals Targeted to receive 75 of funds Must have participated in DSH or UPL programs Allocated on basis of Percent of Medicaid payments, Percent of UPL, Percent of UC Non Hospitals Community mental Health Centers 10 Academic Physicians Practices - 10 Local Health Departments- 5 Conditions Meet minimum number of projects each project capped generally at 20m for 4 years Require participation for major safety net hospitals (at least 4) Broad hospital participation at least 30 of the pool allocated to private hospitals Conditions To be eligible to have a Pass 2, the conditions of Pass 1 must be met Hospitals Non DSH/UPL providers 15 Additional projects for pass 1 participants Non Hospitals Non academic physician practices 10 Additional projects of Pass 1 participants
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Eligibility for Pass 2 Major Safety Net
Hospital Participation

• A minimum number of major safety net hospitals
  must participate in DSRIP as Performing Providers
  based on Tier level.

Tier 1 At least 5
Tier 2 At least 4
Teir 3 At least 2
Tier 4 At least 1
Total At least 38 Major Safety Net Hospitals In Texas
For RHP 9, Major Safety Net hospitals include
Parkland, Baylor University Medical Center,
Methodist Medical Center, Medical City and
Childrens Medical Center
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DSRIP Category 1Infrastructure Development
Category 1 Projects
Expand Primary Care Capacity
Increase Training of Primary Care Workforce
Implement a Chronic Disease Management Registry
Enhance Interpretation Services and Culturally Competent Care
Collect Accurate Race, Ethnicity, and Language (REAL) Data to Reduce Disparities
Enhance Urgent Medical Advice
Introduce, Expand, or Enhance Telemedicine/Telehealth
Increase, Expand, and Enhance Dental Services
Expand Specialty Care Capacity
Enhance Performance Improvement and Reporting Capacity
Implement technology-assisted services (telemedicine, telehealth and telemonitoring to support, coordinate or deliver services.
12. Enhance service availability to appropriate levels of care
13. Development of behavioral health crisis stabilization services as alternative to hospitalizing.
14. Develop Workforce enhancement initiatives to support access to providers t0 providers in underserved markets and areas
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DSRIP Category 2Program Innovation and Redesign
Category 2 Projects
Enhance/Expand Medical Homes
Expand Chronic Care Management Models
Redesign Primary Care
Redesign to Improve Patient Experience
Redesign for Cost Containment
Implement Evidence-Based Health Promotion Programs
Implement Evidence-Based Health Disease Prevention Programs (new)
Apply Process Improvement Methodology to Improve Quality/Efficiency (e.g., Rapid Cycle, Management Engineering, and Lean Technology)
Establish/Expand a Patient Care Navigation Program
Use Palliative Care Programs
Conduct Medication Management
Implement/Expand Care Transitions Programs
Provide an intervention for a targeted behavioral health population to prevent unnecessary use of services in specified setting
14. Implement person-centered wellness self management strategies.
15. Integrate Primary and Behavioral Healthcare Services
16. Provide telephonic/virtual psychiatric and clinical guidance.
17. Establish improvements in care transitions from inpatient settings.
18. Recruit, train and support consumers of metal heath services to provide peer support services.
19. Develop Care Management Function that integrates primary and behavioral health needs of individuals
21
DSRIP Category 3Quality Improvements

• CMS Outcomes Definition
• ..Measures that assess the results of care
  experienced by patients, including patients
  clinic events, patients recovery and heath
  status, patient experiences in the health
  system, and efficiency/cost.
• All Category 1 2 projects must have one or more
  associated Category 3 outcomes.
• Outcomes measured are based on specific patient
  population served by the project.

• Encouraged by CMS to pursue a common,
  regionally-based Category 3 outcome
• A list of Category 3 outcomes is still under
  development

22
DSRIP Category 4Population-focused Improvement

• Potentially preventable admissions
• 30-day readmissions
• Potentially preventable complications
• Patient-centered healthcare, including patient
  satisfaction and medication management
• ED admissions time

23
UC an DSRIP Participation

• Hospitals receiving uncompensated care (UC)
  payments must report on a subset of Delivery
  System Reform Incentive Payment (DSRIP) Category
  4 measures.
• Potentially Preventable Admissions (PPAs)
• Potentially Preventable Readmissions (PPRs)
• Potentially Preventable Complications (PPCs)
• Failure to report on the requirement measures by
  the last quarter of the year (with a six-month
  extension) will result in forfeiture of UC
  payments in that quarter.

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Category Allocations
Hospital Performing Providers
DY 2 DY 3 DY 4 DY 5
Category 1 2 No more than 85 No more than 80 No more than 75 No more than 57
Category3 At least 10 At least 10 At least 15 At least 33
Category 4 5 10-15 10-15 10-15
Non- Hospital Performing Providers
DY 2 DY 3 DY 4 DY 5
Category 1 2 95-100 No more than 90 No more than 90 No more than 80
Category3 0-5 At least 10 At least 10 At least 20
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1115 Waiver as a Foundation for Reform

• Supreme Court decision allowing states to opt out
  of Medicaid Expansion
• 155 Billion being eliminated from Hospitals as
  Health Care Reform is Implemented
• Lessons learned from Massachusetts
• Newly covered individuals not able to find care
  (infrastructure not developed to handle increase
  in covered individuals)
• Without expansion of Medicaid, many Texas
  Hospitals will have a difficult challenge ahead
• 1115 Waiver offers the opportunity to transform
  the delivery system to provide more than cover
  the opportunity to reach the Triple Aim Goals

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Triple Aim

• Institute for Healthcare Improvement, 2007
• 3 critical objectives
• Improve the health of the population
• Enhance the patient experience of care (including
  quality, access, and reliability)
• Reduce, or at least control, the per capita cost
  of care
• Ultimately we must move beyond Coverage and Care
  to the Prevention and the Social Determinants of
  Health

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Fence or Ambulance?
The poem Fence or Ambulance? by Joseph Malins
that was published in the 1913 Bulletin of the
North Carolina State Board of Health opens this
way

• Twas a dangerous cliff, as they freely
  confessed,
• Though to walk near its crest was so pleasant
• But over its terrible edge there had slipped
• A duke, and full many a peasant
• So the people said something would have to be
  done,
• But their projects did not at all tally.
• Some said, Put a fence around the edge of the
  cliff
• Some, An ambulance down in the valley.

Better guide well the young than reclaim them
when old, For the voice of true wisdom is
calling To rescue the fallen is good, but tis
best To prevent other people from
falling Better close up the source of temptation
and crime Than deliver from dungeon or
galley Better put a strong fence round the top
of the cliff, Than an ambulance down in the
valley.
Prevention is better than cure. Desiderius
Erasmus 1466-1536
Malins J. Fence or ambulance? Bulletin of the
North Carolina State Board of Health
191327(10)16 Available at http//www.archive.or
g/stream/bulletinofnorthc27nortpage/16/mode/1up.
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Elements Needed in the Changing Environment

• New delivery models are as important as insurance
  reform
• Rationalizing delivery models
• - Primary medical care homes
• - Care management
• - Addressing socioeconomic determinants of
  health
• - Addressing disparities adequately
• Shift from volume-driven to value-driven
  (outcomes vs. thru-put)
• Access is as fundamentally important as coverage
• Evidence-based practice and policy are critical
• Must deal with variations in practice that are
  not bringing value
• Must promote comparative effectiveness research
  and its applications
• Must balance sticks and carrots

29
Safety Net in the Changing Environment

• Needs to expand upstream and deal with the
  determinants of health at the community level
• Prevention
• Health promotion
• Care management
• Population-driven medicine
• The Safety Net may need to be redefined
• More adaptable and flexible
• More accountable
• More upstream interventions

30
Safety Net in a Changing Environment

• Investment in public infrastructure may be the
  best way for many urban areas to provide the
  elements necessary for reform to succeed,
  especially in these areas
• Physician, nurse and other provider training
• Outcomes studies for comparative effectiveness
  and disparities
• Population medicine
• Provision of regional tertiary/quaternary
  services
• Rethinking the health delivery model, moving from
  individual medicine to population health
• Need incentives to improve collaboration among
  hospitals, public health and community-based
  services
• Meet as a community to determine how to harvest
  the synergy of education, housing, police, fire,
  etc.

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Recreate the Commons

• Restore our sense of community
• Re-tap our energy to solve our own problems
• Rediscover the strengths of ad hocracies
• De Tocqueville early 1800s
• Effects will be seen in areas other than health
  care

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Managing the In-Betweens

• We must manage the In-Between, or the Common
  Ground that benefits the whole infra-structure
  but is not managed by any one part
• Important for accountability, stewardship and
  outcomes
• Promotes synergism with one success building upon
  another

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Call to Action

• To improve quality, safety access
• Goals for Dallas to bring us together Healthy
  Dallas Goals for United Way Strategic Plan
• Collaborative Dialogue
• Community Driven Process
• (Managing the In-Betweens)
• Regional Health Partnerships
• Planning for Health Among Competitors
• (1115 Medicaid Waiver)