Texas Healthcare Transformation

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Texas Healthcare Transformation Quality
Improvement ProgramMedicaid Section 1115
DemonstrationAka The WaiverLeslie Carruth,
MBAOffice of Health Affairs

• CSE
• September 26, 2013

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Through the Storm
Public Policy

Health Care Reform
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Medicaid

• State-federal partnership enacted in 1965 to
  provide health insurance coverage to eligible
  persons
• CMS issues policy rules for State Plans
• Minimum guidelines for eligibility, services
• States may expand coverage
• FMAP average 57 Texas 58.5
• Texas Medicaid agency is HHSC

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Texas Perspective

• Escalating cost burden
• Highest rate of uninsured in US
• Frayed or non-existent safety net
• Political philosophy

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Federal perspective

• Escalating cost burden
• Affordable Care Act - March 2010
• Expanding Medicaid eligibility in 2014
• Supreme Court decision June 2012
• Medicaid expansion is optional for states

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Health Care ReformTriple Aim

• Improving the patient experience of care
• Including quality satisfaction
• Improving the health of populations
• Reducing the per capita cost of health care
• Dr. Don Berwick
• CMS Administrator, July 2010 to December 2011

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Medicaid waivers

• Section 1115 Research Demonstration Projects
• Section 1915(b) Managed Care Waivers
• Section 1915(c) Home Community-Based Services
  Waivers
• Texas has a 1915(b) and 8 1915(c) waivers
• All states about 400 current/pending waivers

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Section 1115 Demonstrations

• HHS Secretary may approve demonstration projects
  that give States additional flexibility to design
  improve their programs
• Purpose demonstrate evaluate policy approaches
  such as
• Expanding eligibility to individuals who are not
  otherwise Medicaid or CHIP eligible
• Providing services not typically covered by
  Medicaid
• Using innovative service delivery systems that
  improve care, increase efficiency, and reduce
  costs
• Must be budget neutral to the federal
  government

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HHSC Proposal to CMS

• Dual purpose
• Expand existing Medicaid managed care programs,
  STAR and STARPLUS, statewide
• Establish two funding pools to assist providers
  with uncompensated care costs and promote health
  system transformation
• Improve care delivery systems and capacity while
  emphasizing accountability and transparency, and
  requiring demonstrated improvements at the
  provider level for the receipt of such payments
• No mention of expanding coverage

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Budget Neutral Proposal June 2011

• Projected Texas Medicaid Costs FY 2012-2016
  (Billions)

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Budget Neutral?
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CMS Approves Texas 1115

• HHSC gets the news December 12, 2011
• Waiver period is Oct 1, 2011 to Sept 30, 2016
• Planning Year, DY 1, ends Sept 30, 2012
• Develop new UC tools based on cost reporting
• Organize into RHPs
• Program Funding Mechanics Protocol August 2012
• DSRIP Planning Protocol (projects menu)

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DSRIP and UC Pools
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RHPs

• 20 Regional Healthcare Partnerships
• Vary in size 2 to 47 counties
• Tier 1 to 4
• DSRIP allocated by formula
• Anchor
• Not the Banker
• Guides, coordinates, administers
• Critical variance in IGT capacity

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Players

• Performing Providers
• IGT Entities
• Inherent conflicts
• Transformation by Hospitals?
• Public vs Private Entities
• Integrating primary and behavioral care
• Who leads?
• Critical variance in IGT capacity (worth saying
  twice)

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DSRIP Categories

• Category 1 Infrastructure development
• Category 2 Program innovation and redesign
• Category 3 Population-focused improvement
• Category 4 Clinical improvements in care
  

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Project Design

• Responsive to community need
• Strategic
• Sustainable
• Impact on target population
• Medicaid and low-income uninsured

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Milestones Metrics

• Primarily menu driven in Category 1, 2 3
• Standardized for Category 4
• Pay for reporting data from HHSC

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Quality Issues

• Metrics appropriateness, baselines
• Process or Outcome
• Time Horizon

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Project Valuation

• NOT cost-based reimbursement
• Incentive payments
• Project impact on waiver aims
• Quantifiable Patient Impact (summer 2013)
• Art rather than science

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Learning Collaboratives

• Added requirement by CMS
• RHP level and state-wide
• Implications for CSE
• Your expertise will be an asset

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UTs Role

• Convened Academic Medicine/HHSC meetings
• Code Red 2012
• UTMB and UTHSC Tyler serve as Anchors
• UTHSCSA in South Texas
• White paper to include GME projects
• Participated in UC Tools development

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UTs DSRIP Participation
Theres no such thing as a free lunch.
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Progress report

• DY 2 ends Monday. Time to report metrics
• Projects are not yet fully approved thru DY 5
• Initial approval received May 2013
• QPI required in July
• Resubmissions approved a few weeks ago
• Category 3 metrics not yet clearly defined
• Bright spot late achievement allowable

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• Questions?
• Thank you!