A Tale of Three Regions: Texas’ 1115 Waiver Journey
Regional Healthcare Partnership 3
Shannon Evans, MBA, LSSGB
Regional Healthcare Partnership 6
Carol Huber, MBA
Regional Healthcare Partnership 1
Daniel Deslatte, MPA
REGIONAL HEALTHCARE
PARTNERSHIP 3
Shannon Evans, Manager, Health System Strategy Operations
2
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1115 WAIVER BACKGROUND
MEDICAID SUPPLEMENTAL PAYMENTS
• Direct reimbursement for services has been below
provider costs for many years and continues to shrink
• To assist providers caring for a large percentage of
Medicaid and/or uninsured patients, programs were
created:
• Disproportionate Share for Hospitals (DSH)
• Upper Payment Limit (UPL)
UPL PROGRAM
•
•
Payments not to exceed what Medicare would have paid for the same service
States use IGTs to provide the state’s contribution to these UPL payments
1115 WAIVER 101
•
1115 Waiver: A CMS approved waiver to the Social Security Act that currently
funds Medicaid. Provides flexibility for Texas to expand risk-based managed care
statewide and preserve UPL funding; redirects the supplemental payments that
historically existed under the UPL program in order to improve care delivery
systems and capacity, while emphasizing accountability and transparency, and
requiring demonstrated improvements at the provider level for the receipt of
funding.
•
Uncompensated Care (UC) Pool: Funding available to RHP participants under
the waiver to defray UC costs. This is a completely separate pool from DSRIP
pool and funding established to help defray UC costs provided to Medicaid
eligible or to individuals who have no source of third party coverage.
•
Delivery System Reform Incentive Payments (DSRIP) Pool: Initiatives designed
to provide incentive payments to hospitals and other providers for
investments in delivery system reforms that increase access to health care,
improve the quality of care, and enhance the health of patients and families
they serve.
www.setexasrhp.com
Regional Health Partnership 3 (RHP3)
•There are 26
providers with
active DSRIP
projects, including:
•Hospitals
•Academic Health
Science Centers
•Local Public
Health
Departments
•Local Mental
Health Authorities
Provider
RHP3 Quick Facts:
•9 counties
•8,580 square miles
•4.8 million residents
•51% Anglo/31%
Hispanic
•16.8% live below
poverty line
•8% average
unemployment
•26% without health
coverage
•$50,363 per capita
income
County
•Providers selected
project areas from a
menu called the RHP
Planning Protocol
•190 outcome
measures were
selected by RHP3
providers.
•All proposed
projects were
reviewed and
approved by HHSC
and CMS.
•Baselines were set
in DY3.
•Incentives are paid
for achieving
approved milestones
and metrics.
Project
Focus
•DY4 incentives will
be paid for
reporting and
performance.
•Providers choose
one re more
community needs.
•RHP3 includes 25
community needs
derived from over
40 community
needs assessments
throughout the
Region
•DY5 incentives will
be paid for
performance only.
Outcome
Measure
177 Projects worth
approximately $2.2 billion in
incentive payments
Community
Need
Local Mental Health
Authorities (LMHAs)
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KEY REGIONAL CHALLENGES
•
•
•
•
•
•
•
•
•
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Inadequate number of primary and specialty care providers
High prevalence of chronic disease
Diverse patient population, varying economic, educational and cultural
backgrounds
High number of Uninsured Patients
High prevalence of behavioral health conditions and lack of an integrated
care solutions
Fragmentation of patient services throughout a large, uncoordinated
health care system
Limited access to public transportation and emergency services
Aging population and increased need for high cost services
Inadequate IT infrastructure for improved care coordination
#VITAL2016
Community Needs
Inadequate access
to primary care
Inadequate access
to specialty care
Inadequate access
to behavioral
healthcare
Inadequate access
to dental care
Inadequate access
to care for veterans
High rates of
inappropriate ER
utilization
High rates of
preventable
hospital
readmissions
High rates of
preventable
hospital admissions
Insufficient access
to services for
pregnant low
income women
Inadequate access
to care for those
with special needs
Inadequate access
to care coordination
High rates of chronic
disease &
inadequate access
to services
High rates of
tobacco use &
excessive alcohol
use
High teen birth rates
High rates of poor
birth outcomes low
birth-weight babies
Shortage of primary
and specialty care
physicians
High rate of sexually
transmitted
diseases
Insufficient access
to integrated care
behavioral
healthcare
Lack of
immunization
compliance
Lack of access to
programs
providing health
promotion
Inadequate
transportation
options
Insufficient access
to services designed
to address
disparities
Lack of patient
navigation
Limited use of
electronic health
records
Graduate medical
education
REGION 3 DSRIP PROJECT FOCUS
Chronic Care
Behavioral Health
Patient Navigation
Healthcare
Transformation
Process
Improvement /
Patient Experience
Emergency Center
Utilization
Primary / Specialty
Care
REGION 3 QUANTIFIABLE PATIENT IMPACT
Encounters
• DY 3-4 Actual: 926,421
• DY 3-4 Target: 813,741
• DY 3-4 Achievement:
114%
Individuals
• DY 3-4 Actual: 715,109
• DY 3-4 Target: 325,456
• DY 3-4 Achievement:
220%
QUALITY OUTCOME DOMAINS
Primary Care and
Chronic Disease
Management
Potentially Preventable
Admissions
Potentially Preventable
Readmissions
Potentially Preventable
Complications
Cost of Care
Patient Satisfaction
Oral Health
Perinatal Outcomes
and Maternal & Child
Health
Right Care, Right
Setting
Quality of Life /
Functional Status
Behavioral Health /
Substance Abuse Care
Primary Prevention
Palliative Care
Healthcare Workforce
Infectious Disease
Management
REGION 3 COHORTS ACCOMPLISHMENTS
Patient Navigation
EC Utilization
Behavioral Health:
Continuity of Care
Integrated Care
Readmission
Collaboration Best
Practices
Start Date
2013
2014
2014
2014
2015
Goal / Charter
Develop two
comprehensive web
based tools:
• Patient navigation
Outcomes
• ID common best
• Decrease non• ID strategies to
• Engage
practices and process
emergent EC visits
address all cause 30providers to
improvement /
day readmission rates
collaboratively
implementation
• Increase area
impact
clinics visits
regional
• Evaluate Primary
• Regional Continuing
readmission
Behavioral Health
Education Tool for
rates
Care via the
CHWs
Organizational
Assessment Toolkit
(OATI)
• Memorandum of
• Evaluation of
• Analysis of regional
• Completed a • Shared document with
community partners
Understanding with
navigation models
hospital discharge
survey to
institutions to share
data correlating
identify
• Discussing challenges
data
• Meetings with ECs
patient characteristics
specific
to collaboration
to: prevent
with readmission
readmission
• Development of
inappropriate EC
focus areas
Navigation website
use and navigate
• OATI pilots
patients to area
clinics
REGION 3 SUCCESSES
•
•
•
•
•
•
Collaboration & Shared Learning
Community Engagement
Additional Services/Programs
Improved Patient Outcomes
Improved Patient Access
Cost Savings
REGION 3 NEXT STEPS/CHALLENGES
•
•
•
•
•
Waiver Renewal
Further Community Engagement
Shift in Funding Weights
Downstream Healthcare Impact
Sustainability
• Alternative Payment Models
REGIONAL HEALTHCARE PARTNERSHIP 3
Keep Calm and DSRIP On!
For additional RHP 3 updates and information please visit
www.setexasrhp.com
You can also contact the RHP3 Anchor team at
[email protected]
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Regional Healthcare Partnership 6
Carol Huber, RHP 6 Director
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RHP 6 Community Needs Addressed
through DSRIP Projects and Collaboration
CN 1
CN 2
CN 3
CN 4
CN 5
CN 6
Quality of
care in Texas
is below the
national
average
High rates of
chronic
conditions
require
improved
management
and
prevention
51
58
52
42
5
4
projects
projects
projects
projects
projects
projects
Lack of
integrated
behavioral
health
services
Poor access
to medical
and dental
care
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Poor
maternal and
child health
outcomes
High rates of
communicable
and vaccinepreventable
diseases.
How does RHP 6 compare to the entire state?
Variable
Texas
RHP 6
RHP 6 Range
Percent Hispanic
38%
54%
17 - 94%
Percent of residents ages 18-64
64%
62%
50 - 64%
Percent of residents with less than high school
education
20%
19%
9 – 42%
Percent of deaths due to cardiovascular disease and
diabetes
34%
34%
30 - 75%
Percent of mothers under 18 years of age
4.9%
5.5%
3 - 33%
$38,609
$35,989
$18K – 50K
8.2%
7.4%
5 - 16%
16.5%
16.2%
9 - 35%
26%
24%
19 - 37%
Per capita personal income
Unemployment rate
Percent living below poverty
Percent uninsured
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Source: RHP 6 Plan, submitted to HHSC December 2012
RHP 6 Projects
Behavioral Health (37)
6%
5%
7%
30%
Primary Care (23)
7%
Care Mgmt/Navigation
(20)
Specialty Care (13)
11%
Health Promotion (9)
18%
16%
23
Process Improvement
(9)
Telemedicine (6)
RHP 6 Interactive Tool
http://www.texasrhp6.com/rhp6-public-meeting/
Project Challenges and Lessons Learned
Challenges
• Planning and coordination
• Provider /staff recruitment and
retention
• Technology, equipment and space
• Data
• Policy, legal, or contract challenges
• Securing buy-in and
communicating effectively
• Patient participation
Lessons Learned
 Value of partnerships and
communication
 Importance of planning
 Good use of technology and data
systems
 Ability to adapt and use resources
efficiently
 How to recruit providers
Transformation is…
Collaboration among providers and stakeholders
Performance
Bonus Pool?
Cross-sector
workgroups
Set common aim
Address project challenges
“Actionable”
project list
Networking
Opportunities
Through their design and leadership,
Regional Healthcare Partnerships drive
collaboration and transformation.
Readmissions Learning Collaborative
•
Based on the Institute for Healthcare
Improvement Breakthrough Series Model
•
Partners in learning with UTMB / RHP 2 and
the Improvement Science Research Network
•
Engagement from hospitals, community
mental health centers, health plans, HASA,
academic researchers, and community
partners
• Shared Aim: Reduce
readmissions by 5%
– 10 hospital teams signed up to
participate
– 7 teams completed the entire process
(attrition due to staffing resources and
data issues)
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DY 5 ACES
Align * Collaborate * Evaluate * Sustain
• Align
– Document regional strategies/efforts for addressing community needs.
– Identify active participants and community stakeholders working on each area of
need to better promote and facilitate collaboration among key entities.
• Collaborate - Organize and facilitate meetings targeting relevant and
engaged providers and stakeholders to better understand and maximize
opportunities for alignment.
• Evaluate
– Identify key indicators and assess how DSRIP is improving health and transforming
care in RHP 6.
– Provide program evaluation technical assistance and peer review to DSRIP
providers.
– Aggregate and communicate RHP 6 DSRIP outcomes.
• Sustain - Explore and promote strategies and opportunities for sustaining
successful DSRIP projects beyond waiver funding.
Why focus on program evaluation
and sustainability?
4
3
2
1
Continue
project in
Waiver 2.0?
DY6
milestones=$$
5
Life after
DSRIP
Waiver 2.0
updates (QPI,
MLIU, “next
logical step”)
DY5
Stretch
Activity 3
And… Contribute to the transformation “body of knowledge”
And… Provide best care and services for patients
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What is required for sustainability?
• It takes
more than
just money.
https://sustaintool.org/
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What is
REALLY
required for
sustainability?
Logic
Model
Env’t
Support
Org
Capacity
Funding
Stability
Data
Plan
Program Evaluation
Sustainability
Partnerships
Program
Adapt’n
Strategic
Planning
Communication
RHP 6 Sustainability Assessments:
Domain Score vs Ability to Impact
7
Ability to Impact
6.5
Organizational Capacity
6
Strategic Planning
Program Evaluation
Program Adaptability
Communications Environmental Stability
5.5
Partnerships
5
4.5
Funding Stability
4
4.0
4.5
5.0
5.5
Domain Score
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6.0
6.5
7.0
Completed assessments:
76 of 124 projects (61%)
18 of 24 providers (75%)
“Sustainability Retreat” Learning Collaborative
May 2016
Are
we
there
yet?
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Cat 3 Outcomes… so far!
Cat 3 Outcomes Reported
October DY4
30
Outcomes Achieved
•
•
•
•
•
•
•
Fully Achieved
Partially
Achieved
4
92
QPI (October DY4 Reported)
Not Achieved
Projects Reporting
Diabetes Care and Control
Readmissions
ED Throughput
Quality (Falls, CAUTI, Stroke)
Patient Satisfaction
Low Birth Weight births
Preventive Care
DY4 Result
DY4 Target
Patients Served /
Positively Impacted
78
197,436
150,173
Patient Visits /
Encounters
42
384,036
236,314
82% of projects have achieved their DY5 target
DSRIP Incentives Earned (DY 1-4)
DSRIP Incentives (All Funds)
$58,414,641
$227,089
Earned
Not Yet Earned
Lost
Provider Achievement of Allocated
DSRIP Incentives
0
1 1
40-49%
2
50-59%
$796,881,504
3
60-69%
70-79%
18
80-89%
90-100%
RHP 6 Logic Model (conceptual)
Inputs
Activities
Collaborative
learning
Performing
Providers
Financial
investments
Staff
Facilities
HHSC/CMS
Policy
Process and
Improvement
milestones and
other efforts,
including:
Short/Medium Term
Outcomes
Cat 3 outcomes
Potentially Preventable
Events (Cat 4)
Patient satisfaction
Reduce cost of care
Enroll patients
Increase provider capacity
Conduct patient
visits
Improve performance on
HEDIS and other quality
measures
Develop &
implement
protocols
Care transitions
Long Term
Outcomes
Incidence/prevalence of
infectious and chronic
disease
CHW encounters
Recognize / Address / Impact social determinants
Achieve collaborative cross-sector integrated system of care
Mortality
Years of
Potential
Life Lost
Health
Equity
Contact Information
Carol Huber
Director, RHP6
[email protected]
Regional Healthcare Partnership 1
Daniel Deslatte, MPA
Vice President – UT Health Northeast
About the UT System
• Founded in 1883, now nine general academic institutions, and
six health-related institutions:
- 90,000+ employees
- $15 billion annual operating budget
- Currently adding two new health-related institutions
• As a health system, the University of Texas is the most
significant provider of healthcare in Texas:
- 2,000 inpatient beds owned or operated
- 78,000 admissions for 1.45 million inpatient days annually
- 6.85 million outpatient encounters last year
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Our Role
• UT Health Northeast has three roles in the 1115 Waiver:
- Anchor: Administrator for the Northeast Texas Regional
Healthcare Partnership, roughly $1.2 billion partnership
with three dozen providers, including hospitals, mental
health authorities, and public health departments
- Provider: Responsible for $160 million in DSRIP projects
- IGT Entity: Provides the non-federal share of waiver
payments based on Federal Medical Assistance
Percentages (FMAP)
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Start With Why
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Northeast Texas
Northeast Texas
Texas
Population
1.3 million
25.1 million
Counties
28
254
Rural Population
53.9%
17.5%
Median Age
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33.6
Per Capita Income
$19,386
$24,870
Bachelor’s Degree
13.2%
25.8%
Minority Population
24.8%
29.6%
Hispanic Origin
13.1%
37.6%
Northeast Texas is older, poorer, less well educated and
at greater risk of early death than the state average.
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Sample Projects
• Behavioral Health: Crisis stabilization centers, jail diversion
projects, behavioral-physical health integration, technology
infrastructure to better coordinate care
• Primary/Specialty Care: Creation of medical homes, expanded
hour clinics, pediatric obesity interventions, emergency room
diversion programs, pediatric asthma
• Other: Community health worker training, potentially
preventable admissions/readmission reduction programs,
cancer screening and early detection
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Initial Outcomes
• At least 500,000 new encounters for patients in underserved
rural communities.
- At least 50,000 encounters in behavioral health
- Primary care, care coordination, and medical home account
for the largest amount of new encounters and individuals
• Quality indicators are trending upwards:
- RHP 1 beats the Texas average on half of proposed bonus
pool Medicaid quality indicators
- Individual provider level quality metrics are encouraging
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Pediatric Asthma
• Breath of Life Mobile Clinic partners with 36 school districts in
11 Northeast Texas counties to help keep kids out of the
hospital and emergency room and in school and activities
• Serves 2,400 children
• 80% reduction in ED Use
• 90% reduction in hospitalization
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Challenges for UC Providers
• Declining UC Caps: UC allocation drops from 88% of total
funding 2011 to 50% in 2016.
• Shift from UPL Model to UC Model: UC funds are harder to
access than historic UPL funding.
• Limited IGT Sources: IGT funds are finite, and there are
competing demands, including DSH and DSRIP.
• Other Federal Funding Issues: Federal sequestration, rate cuts,
audits, and recoupment is additional strain on health systems.
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DSRIP Revenue Recognition
Expense
Revenue
Recognition
Payment
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FY 13
(DY 2)
PM 1
PM 2
PM 3
PM 1
PM 3
FY 14
(DY 3)
FY 15
(DY 4)
PM 2
PM 1
PM 3
PM 2
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Lessons Learned & Trends
• Increasing emphasis on collaboration among providers
- Evolution from learning collaboratives (MA) to Regional
Healthcare Partnerships (TX) to Performing Provider Systems (NY)
- Locally designed with flexibility, but expectation of a rigorous
process that includes entire communities
• Increasingly difficult expectations
- TX: Risk based, pay for performance projects with a shift from
process to outcomes measures
- Increasing focus on population health and risk
- Different perspectives on valuation
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Lessons Learned & Trends
• DSRIP is about transformation of the entire healthcare system,
including non-hospitals
- CMS is very focused on what happens after DSRIP
- Focus on community needs assessments that feed DSRIP project
planning and involve non-hospital providers
• Trend towards data driven environment
- How do you demonstrate value?
- Difficult balance between rigorous analysis and ability to make
course corrections
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Contact Information
Daniel Deslatte, MPA
Vice President, Planning & Public Policy
UT Health Northeast
Direct: 903-877-5077
[email protected]
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Discussion
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