The Changing Healthcare Environment:
1115 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
• Waiver’s 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).
Proposed RHP Map
5
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)
DSRIP Pool – Funding Flow
• Public Hospital
• In areas with no public hospital:
• Hospital District
• Hospital Authority’
• County
• State University with HSC or medical school
Reporting
Anchor
RHP
Administrative
Functions
HHSC
Approves
performance
IGT Entity
Reviews
performance
Examples:
Public Hospital
Public Hospital
Public Hospital
LMHA
Payments
Funding
Source
HHSC
Requests IGT
from IGT Entities
CMS
Approves Federal
match and sends to
HHSC
Performing
Provider Reports
Performance
Examples:
Public Hospital
Private Hospital
Private Hospital
LMHA
Clinic
IGT Entity
Provides IGT to
the State
HHSC
Requests federal
match from CMS
HHSC
Provides payments to
performing provider
Performing Subcontractor
Reports performance to
performing provider
Performing Provider
Receives payments
Performing
Subcontractor
Receives
payments from
performing
provider.
8
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 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.
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
Centers for Medicare and
Medicaid Services (CMS)
Texas Health and Human
Services Commission
(HHSC)
Dallas County Hospital
District
Board of Managers
(DCHD – Dallas Anchor)
Regional Healthcare
Partnership (RHP)
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
Dallas Medical Resource
Oversight Work Group
Co-Chairs
Tom Royer MD and Joel Allison
(Dr. Royer was replaced by Ted Shaw)
1115 Waiver Steering
Committee
Tom Royer MD (Dr. Royer
replaced by Ted Shaw)
Committee replaced
with the Plan Writing
Committee
Delivery System Redesign
Incentive Pool Task Force
Co-Chairs
Ron Anderson MD and David
Ballard MD
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
Uncompensated Care Pool
Task Force
Co-Chairs
John Dragovits and Fred
Salvelsbergh (John Dragovits
replaced by Jody Springer)
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
Organizing & Learning
Planning
Assessment
•DSRIP Development &
Coordination (Support
& Guidance for RHP
participants)
•RHP Proposal
Development
•Participant and
Electeds Buy-In &
Engagement
•Interviews, Focus
Groups & Survey
•Provider Assessments
(Readiness, Strengths
& Gaps)
•IGT Assessment
(Finances/available
funds)
•Community & Regional
Needs Assessments
•Orientation
•Education &
Communication
•Engagement
•Committee
Development
•Consensus on
Principles for Success
•Establish
“Collaborative”
Governance
Phase 1: Local Partner
Development
Today (April 20 2012)
April
• Stakeholder
engagement
• RHP
Committee
formation
•Execution & Partner
Development at
Local Level
•Elevate “the game”
of individual players
& health networks in
each county
•Achieve process &
preliminary
milestones
6 Month
May
June
• 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
Phase 2: Regional
Execution
Year 1
Year 2
July
• Develop RHP-wide Community Needs
Assessment
• Begin RHP Plan Development
• Community forums for plan review
• Finalize DSRIP plans
•Synergy of RHP Partners
•Implementation of
Regional Strategies
•Learn to play well
together as a region,
elevating performance as
a team to provide better
care at lower cost for RHP
•Achieve broader
outcomes & long-term
milestones
Year 3
August
• Draft plans to
THHSC 8/1
• Draft plans to
CMS 8/31
Year 4
September
• Review/
update
plans
based on
feedback
Year 5+
October
• Final
plans to
CMS
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
Transparency
Ensure that decision making process takes
place in the public eye and that processes are
clear to participants
Patient-Centered
RHP and criteria should focus on improving
patient care & experience through more
efficient, patient-centered and coordinated
system
Collaborative
RHP informed by collaborative process that
reflects the needs of the community(s) in
inputs of stakeholders
Value-Driven
RHP should focus on increasing value to
patients, community, payers and other
stakeholders. Better Care, Less Cost
Accountability
Stakeholders are held to common
performance standards, deliverables and
timelines
Pool Funding Distribution
Transformation is the Goal
Pool Funding Distribution in Billions
DY* 1
DY 2
DY 3
DY 4
DY 5
Pool Type
UC
DSRIP
(2011-2012)
(2012- 2013)
(2013- 2014)
(2014-2015)
(2015-2016)
$3.7
$0.5
$3.9
$2.3
$3.534
$2.666
$3.348
$2.852
$3.1
$3.1
Totals
$17.582
$11.418
Total/DY
$4.2
$6.2
$6.2
$6.2
$6.2
$29
% UC
88%
63%
57%
54%
50%
60%
% DSRIP
12%
37%
43%
46%
50%
40%
Page 11
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
>15%
20
10
Tier 2 (Regions 9
and 10)
7-15%
12
6
Tier 3
3-7%
8
4
<3%, no public hospital,
or public hospitals serve
<15% UC
4
1
Tier 4 (Region 18)
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
14
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.
15
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
Allocate from
State
Pool to Regions
for years 205
 Percent of population < 200%
FPL
 Percent of Medicaid acute care
payments
 Percent of UPL program
payments
Pass 1 Allocation within RHP to
Performing Provider
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
Pass 2
Allocation of
Excess Funds
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
At least 38 Major Safety
Net Hospitals In Texas
Total
For RHP 9, Major Safety Net hospitals include:
Parkland, Baylor University Medical Center, Methodist
Medical Center, Medical City and Children’s Medical
Center
DSRIP Category 1:
Infrastructure Development
Category 1 Projects
1.
Expand Primary Care Capacity
2.
Increase Training of Primary Care Workforce
3.
Implement a Chronic Disease Management Registry
4.
Enhance Interpretation Services and Culturally Competent Care
5.
Collect Accurate Race, Ethnicity, and Language (REAL) Data to Reduce Disparities
6.
Enhance Urgent Medical Advice
7.
Introduce, Expand, or Enhance Telemedicine/Telehealth
8.
Increase, Expand, and Enhance Dental Services
9.
Expand Specialty Care Capacity
10.
Enhance Performance Improvement and Reporting Capacity
11.
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
Page 19
Page
20
DSRIP Category 2:
Program Innovation and Redesign
Category 2 Projects
1.
2.
3.
4.
5.
6.
7.
8.
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)
9.
10.
11.
12.
13.
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
Implement person-centered wellness self management strategies.
Integrate Primary and Behavioral Healthcare Services
Provide telephonic/virtual psychiatric and clinical guidance.
Establish improvements in care transitions from inpatient settings.
Recruit, train and support consumers of metal heath services to provide peer support services.
Develop Care Management Function that integrates primary and behavioral health needs of individuals
14.
15.
16.
17.
18.
19.
DSRIP Category 3:
Quality Improvements
CMS Outcomes Definition:
“…..Measures that assess the results of care experienced by patients,
including patients’ clinic events, patient’s 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
Page 21
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
Page 22
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.
24
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
Category 1 & 2
Category3
DY 2
DY 3
DY 4
DY 5
95-100%
No more than
90%
No more than
90%
No more than
80%
0-5%
At least 10%
At least 10%
At least 20%
25
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
26
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
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.”
Prevention is
better than
cure.
Desiderius
Erasmus
1466-1536
“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”.
Malins J. Fence or ambulance? Bulletin of the North Carolina State Board of Health 1913;27(10):16
Available at: http://www.archive.org/stream/bulletinofnorthc27nort#page/16/mode/1up.
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”
28
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
29
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.
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
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
Health in
All
Policies
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)