Texas Institute of Health Care Quality and Efficiency

1. Texas Institute of Health Care Quality and Efficiency Monday September 15, 2014 • Work Group Meeting #3 10:00 a.m. – 1:30 p.m. www.ihcqe.org

2. IHCQE Work Group Meeting • September 15, 2014 High Level Overview of Agenda: 10:00 a.m. – 12:30 p.m. • Welcome and overview: Dr. Steve Berkowitz, IHCQE Chair • Introductions • Staff Updates on Expanded Access to Care Welcome and Overview 10:00 – 10:40 1 • Expanded Access to Care (Dr. Marin and Mr. Allison) Panel and Board Discussion Expanded Access to Care 10:40 – 12:10 2 • Staff Update on other topic areas (if necessary and time permits) 2014 Topic Areas 12:10 – 12:20 3 • Public comment • Final board actions: Dr. Steve Berkowitz • HHSC staff action items: Mr. Jimmy Blanton • Adjourn meeting Public CommentStaff Action Items 12:20 – 12:30 4 Times are approximate and may be adjusted

3. IHCQE 2014 – Expanded Access to CareMeeting Objectives • Discuss expanded access to care with panel experts • Finalize Guiding Principles • Identify 3-4 Proposed Recommendations

4. IHCQE 2014 – Expanded Access to CareInstitute Priority Proposed Topics for Recommendations SPMI Health Literacy Choosing Wisely Core Quality Metrics Administrative simplification Data Sharing THCIC Promoting value based care Expanded coverage Prevention Acquired brain injury Transparency Institute Operations Topic Area Prioritization Promoting Value Based Care: 17 Choosing Wisely: 13 SPMI: 12 Expanded Coverage: 12 Administrative Simplification: 11 Topics Approved Promoting Value Based Care: 17 Choosing Wisely Health Literacy: 13 SPMI: 12 Expanded Coverage: 12 Administrative Simplification: 11

5. IHCQE 2014 – Expanded Access to CareSuggested Recommendations – June 2014 • Medicaid expansion • Options from other states • Private sector options • Community public/private partnerships • Value-Based Payment Reform • Community health worker reimbursement • Deductible reform with exchange plans • Interventions or pilot/demonstration projects • Promotion of social programs and community services (e.g. transportation) • Cultural competent • Enhanced provider access • Identify and engage super-utilizers at regional level • Telehealth expansion • Expansion of loan repayment options for urban underserved providers • Incentivize and simplify seed money for FQHCs • Remove barriers and access to Rx due to Exchange Plans

6. IHCQE 2014 – Expanded Access to CareHigh Level Questions • How can Texas provide better access to care for low income individuals who are currently ineligible for Medicaid and lack access to affordable private health coverage? • Can and should we increase access through existing initiatives such as the 1115 Medicaid Transformation waiver, through expansion of the traditional Medicaid program, or by subsidizing and promoting access to affordable private health insurance coverage? • As access to care improves, how does the state promote the use of higher value services? • Increased health insurance does not necessarily mean access to care.

7. IHCQE 2014 – Expanded Access to CareTexas Medicaid Eligibility

8. IHCQE 2014 – Expanded Access to CareUninsured in Texas (Prior to Exchange) • According to data from the Texas Behavioral Risk Factor Surveillance System (BRFSS, 2012), about 36% of the state’s non elderly adult population (age 18 – 64) are uninsured. • Demographic breakouts include: • 59% of Texas Hispanics • 46% of individuals age 18 – 29 years • 64% in household with under $25,000 annual income • Could not see doctor due to cost in past 12 months • Overall: Insured = 13%, Uninsured = 42.5% • Less than $25k income: Insured = 31%, Uninsured = 47% • Routine check-up in past year • Overall: Insured = 71%, Uninsured = 38% • Less than $25k income: Insured = 69%, Uninsured = 35% • 58% of uninsured, non elderly adults in Texas are employed; 8% are out of work less than 1 year; 15% are homemakers

9. IHCQE 2014 – Expanded Access to CareImpact of Excange? Gallup Survey Results, Mid Year 2014 • Change in Texas according to Gallup: Uninsured (2013): 27% Uninsured Midpoint (2014): 24% % Reduction in Uninsured: 11% • Change in U.S. according to Gallup: Uninsured (2013): 17% Uninsured Midpoint (2014): 13% % Reduction in Uninsured: 23%

10. IHCQE 2014 – Expanded Access to Care10 States with Largest Drop in Uninsured Rate

11. Impact of Medicaid Expansion on Hospital Volume Colorado Hospital Association. (2014). Impact of Medicaid Expansion on Hospital Volumes. Retrieved August 20, 2014 from http://www.cha.com/Documents/Press-Releases/CHA-Medicaid-Expansion-Study-June-2014.aspx.

12. IHCQE 2014 – Expanded Access to CareOregon Medicaid Expansion Study • In 2008, Oregon initiated a limited expansion of its Medicaid program by drawing names by lottery • Provided an opportunity to study the effects of Medicaid coverage using a randomized controlled design • Medicaid coverage increased emergency department utilization by 40% relative to the control group • Increased emergency department utilization was noted across a broad range of types of visits, conditions, and subgroups, including for conditions that may be most appropriately treated in a primary care setting • Utilization did not increase for conditions classified as emergent

13. IHCQE 2014 – Expanded Access to CareInnovation in Expanded Access • Arkansas • First state to establish private plan expansion model • Copay requirements • System reforms: bundled payments/health homes • Pennsylvania • Premium requirements • Wellness incentives • Participation in job training/work program • Indiana • Premium requirements • Health Savings Accounts (HSAs) • Would apply even to adults under the poverty line • Failure to participate would move adults to more basic program

14. IHCQE 2014 – Expanded Access to CareHB 3791, 83rd Legislative Session – The “Texas Solution” • Authors: Zerwas, Sheffield, Howard, Coleman • Block Grant Funding System for State Medicaid Program • Risk-based Medicaid managed care model for acute care • Medicaid sliding scale subsidy to purchase a health benefit plan • Private Market Solutions • Connect low-income residents with coverage  not an entitlement • Cost neutral • Eligibility • < 65 years • Household income at or below 133% FPL • Minimum program requirements • Access to health benefits through managed care delivery model • Personal responsibility and accountability – cost sharing, wellness initiatives • Include pay-for-performance initiatives • Use technology to maximize efficiency

15. IHCQE 2014 – Expanded Access to CareSB 10, 80th Legislative Session – Medicaid Reform Legislative Oversight • Authors: Nelson, Brimer, Carona, Duell, Eltife, Fraser, Harris, Janek, Shapiro; CoAuthors: Gallegos, Hegar, Uresti, Williams; Sponsor: Delisi • Texas Health Opportunity Pool • To reduce # of uninsured and need for uncompensated health care through • Provision of premium payment assistance for uninsured adults and older children (19-20 years) with household incomes at or below 200% FPL • HSA contributions • Creating health care system efficiencies (e.g. EMR) • Cost sharing requirement for consumers • Emphasized primary and preventive care • Authorized HHSC to seek Medicaid waiver to implement • Waiver submitted April 2008

16. IHCQE 2014 – Expanded Access to Care1115 Medicaid Transformation Waiver Conference Overview • Uncompensated Care (UC) Pool $17.6 billion • Replaces UPL • Costs for care provided to individuals with no third party coverage for hospital and other services • Delivery System Reform Incentive Payment (DSRIP) $ 11.4 billion • Support coordinated care and quality improvement through a regional health system approach • 1,491 approved and active DSRIP projects: 25% behavioral health, 20% access to primary care, 18% chronic care management and system navigation • Waiver Continuity • Transition plan (based on experiences) due March 31, 2015 • Texas must request renewal (3 or 5 year) or extension (3 year) by September 30, 2015 • 3 year renewal under current terms and conditions; 5 year renewal changes can be requested by both CMS and HHSC • Will work with stakeholders to develop – Stakeholder meetings Summer 2014 • To be drafted prior to the 84th Legislative Session • Expires September 30, 2016

17. IHCQE 2014 – Expanded Access to Care1115 Medicaid Transformation Waiver Conference Overview • Common Themes • Infrastructure and workforce • Recruitment and retention of providers for small, rural regions • Care coordination, especially for high risk, high cost patients • Adapt HIE and HIT systems to reimburse for outcomes • Community health worker and Telemedicine billing/coding in Medicaid • Hospitals are at risk  need to shift to population health management for revenue (e.g. Per member, per month) • Possible sustainability through integration with existing programs • Need UC to continue • Need to demonstrate ROI

18. IHCQE 2014 – Expanded Access to Care1115 Medicaid Transformation Waiver DSRIP Renewal Considerations • Continue existing projects • Allow for more time to demonstrate outcomes improvement and identify best practices • Alignment DSRIP initiatives with Medicaid Managed Care • For funds not allocated in DY5 • Use for new, promising initiatives or enhance successful projects? • Establish shared bonus pool for high performing RHPs? • DSRIP strengths • Regional approach • Multi-disciplinary providers • Important considerations • Project- and population-level data to demonstrate how DSRIP is improving care for Medicaid and low-income uninsured • Continued need for UC • DSRIP Survey – sustainability, structural/admin changes, financing changes, alignment with Medicaid managed care

19. IHCQE 2014 – Expanded Access to CarePROPOSED Guiding Principles • Strong public health, community, and primary care systems as the backbone of a Texas Solution for expanding appropriate quality access to health care • Promote prevention, wellness, self-management of chronic disease, and personal responsibility; stewardship of state taxpayer dollars; the integration and coordination of health care services; a sustainable safety net; and private health plan options that can bridge existing gaps in coverage • Address technical and infrastructure barriers impacting telemedicine and the establishment of patient centered medical/health homes

20. IHCQE 2014 – Expanded Access to CarePROPOSED GUIDING PRINCIPLES • Maximize the use of federal resources to support healthcare transformation and expanded access to care, particularly the 1115 Medicaid Transformation Waiver • Develop solutions that fit within the social, economic, and political framework of the state • Progress toward this vision begins with increased understanding of who lacks insurance, why they lack insurance, how the uninsured currently access health care services, the impact that lack of insurance has on the costs of health care and what impact the state's Medicaid Transformation Waiver is having on access to care and patient outcomes

21. Institute of Health Care Quality and Efficiency Expanded Access to Care Panel Discussion

22. IHCQE 2014 – Expanded Access to CarePanel Members • Don Gilbert, Consultant/Lobbyist • Helen Kent Davis, Director of Government Affairs, Texas Medical Association • Lisa Kirsch, Texas Health and Human Services Commission, 1115 Medicaid Transformation Waiver • Maureen Milligan, President / CEO, Teaching Hospitals of Texas • Ted Shaw, President / CEO, Texas Hospital Association • Ken Shine, Senior Advisor, Code Red Report • Justin Yancy, Executive Director, Texas Business Leadership Council

23. The Texas Way Program Presented by: Ted Shaw THA president/CEO September 15, 2014 Texas Institute of Health Care Quality and Efficiency Austin, TX

24. The Texas Way Program A private insurance program to get low-wage working Texans covered and healthy.

25. The Texas Way Program: Why It Is Needed • >1 million low-wage working Texans with no access to public or private insurance • $5.5 billion annually in hospital uncompensated care • Inefficient health care spending: • Use of ER as primary source of care • Uncompensated care costs shifted to privately insured and local property taxpayers

26. The Texas Way Program: What It Isn’t • The Texas Way is NOT Medicaid expansion • The Texas Way is NOT access to an open-ended entitlement • The Texas Way is NOT a government handout

27. The Texas Way Program: What It Is • Responsible use of available federal funds • Private market insurance for > 1 million low-wage working Texans • Way to engage consumers in health care decisions • Equity for hospitals and other health care providers to offset reimbursement rate cuts under ACA • Opportunity for Texas to be at forefront of health care innovation

28. The Texas Way Program: Healthy Workforce • Texas leads nation in job growth; has one of nation’s lowest unemployment rates • BUT 25% of state’s population is still uninsured • Small businesses less likely to offer insurance as employee benefit • Texas Way Program will connect 1.1 million low-wage working Texans with private insurance • Result: Healthier, more productive workforce; less absenteeism; less turnover

29. The Texas Way Program: Consumer Engagement • Required use of health savings accounts • Required point-of-service cost sharing • Incentives to work • Penalties for use of ER for non-emergent reasons • Incentives for meeting health benchmarks

30. The Texas Way Program: Impact • Less uncompensated care • Healthier workforce and state economy • Financial relief for privately insured and local property taxpayers • More effective health care system

31. The Texas Way Program: Next Steps • Build a coalition of stakeholders • Identify business leaders willing to be the public face and voice of the Texas Way Program • Generate grassroots support • Target media markets

32. Feedback Questions and comments, please

33. IHCQE 2014 – Expanded Access to CarePanel Members • Don Gilbert, Consultant/Lobbyist • Helen Kent Davis, Director of Government Affairs, Texas Medical Association • Lisa Kirsch, Texas Health and Human Services Commission, 1115 Medicaid Transformation Waiver • Maureen Milligan, President / CEO, Teaching Hospitals of Texas • Ted Shaw, President / CEO, Texas Hospital Association • Ken Shine, Senior Advisor, Code Red Report • Justin Yancy, Executive Director, Texas Business Leadership Council

34. Institute of Health Care Quality and Efficiency Public Comment

35. Institute of Health Care Quality and Efficiency Institute and Staff Action Items

36. Texas Institute of Health Care Quality and Efficiency Monday, September 15, 2014 • Work Group Meeting #3 10:00 a.m. – 1:30 p.m. www.ihcqe.org Meeting Adjourned