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The Changing Healthcare Environment: 1115 Waiver Implementation in Texas


The Changing Healthcare Environment: 1115 Waiver Implementation in Texas Alliance for Healthcare Excellence Dr. Ron Anderson, M.D Sue Pickens, M.Ed. – PowerPoint PPT presentation

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Title: The Changing Healthcare Environment: 1115 Waiver Implementation in Texas

The Changing Healthcare Environment 1115 Waiver
Implementation in Texas
  • Alliance for Healthcare Excellence
  • Dr. Ron Anderson, M.D
  • Sue Pickens, M.Ed.

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.

1115 Waiver
  • Waivers impact is state and local, rather than
  • 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

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).

Proposed RHP Map
1115 Waiver CMS Expectations
  • CMS Expectations
  • Planning process that demonstrates regional
  • Projects selected address community needs
    identified through a Community Needs Assessment
  • Projects selected are the most transformative for
    the region.
  • RHP Plan includes projects that tie into four
    categories established y HHSC to demonstrate
  • Infrastructure
  • Innovation
  • Quality
  • Reporting

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
  • Mid-level professional costs related to direct
    patient care services
  • Pharmacy costs related to he Texas Vendor Drug
  • Excess Medicaid DSH costs not reimbursed via
    the Medicaid DHS program
  • Specific tool for submitting reimbursement
    provided by HHSC through TexNet (not yet

DSRIP Pool Funding Flow
  • 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
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
Texas Healthcare Transformation and Quality
Improvement Program Section 1115 Waiver
Program Region 9 RHP Organization Ensuring
Regional Collaboration
  • Anchors development of the Dallas RHP and the RHP
  • 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)
  • 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
  • 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
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
  • Provide opportunity for public Input and review
    of the RHP Plan
  • Ongoing Dallas RHP Plan administration and

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
Committee replaced with the Plan Writing Committee
Texas Healthcare Transformation and Quality
Improvement Program Section 1115 Waiver
Program Region 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
Pool Funding Distribution Transformation is the
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
  • 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

Dallas Fort Worth Hospital Council Community
Needs Assessment Report. RHP 9 Findings
  • 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
  • Behavioral Health - Adult, Pediatric and Jail
  • 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
  • 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.

Stakeholder Engagement
  • Stakeholder Engagement
  • RHP Participant Engagement
  • Information for Performing Providers including
    hospitals, Community Mental Health Centers,
    Academic Health Science Centers and Local Health
  • 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

RHP Plans and CMS Expectations Regional
  • 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

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
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
DSRIP Category 1 Infrastructure 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
DSRIP Category 2 Program 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
DSRIP Category 3 Quality 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

DSRIP Category 4 Population-focused Improvement
  • Potentially preventable admissions
  • 30-day readmissions
  • Potentially preventable complications
  • Patient-centered healthcare, including patient
    satisfaction and medication management
  • ED admissions time

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.

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
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

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

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
  • Twas a dangerous cliff, as they freely
  • 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
  • But their projects did not at all tally.
  • Some said, Put a fence around the edge of the
  • 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
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
Elements Needed in the Changing Environment
  • New delivery models are as important as insurance
  • Rationalizing delivery models
  • - Primary medical care homes
  • - Care management
  • - Addressing socioeconomic determinants of
  • - 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

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

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
  • Rethinking the health delivery model, moving from
    individual medicine to population health
  • Need incentives to improve collaboration among
    hospitals, public health and community-based
  • Meet as a community to determine how to harvest
    the synergy of education, housing, police, fire,

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

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
  • Promotes synergism with one success building upon

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)