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CS&E September 26, 2013

Texas Healthcare Transformation & Quality Improvement Program Medicaid Section 1115 Demonstration Aka “ The Waiver ” Leslie Carruth, MBA Office of Health Affairs. CS&E September 26, 2013. Through the Storm. Public Policy. Health Care Reform. Medicaid.

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CS&E September 26, 2013

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  1. Texas Healthcare Transformation & Quality Improvement ProgramMedicaid Section 1115 DemonstrationAka “The Waiver”Leslie Carruth, MBAOffice of Health Affairs CS&E September 26, 2013

  2. Through the Storm Public Policy Health Care Reform

  3. 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

  4. Texas Perspective Escalating cost burden Highest rate of uninsured in US Frayed or non-existent safety net Political philosophy

  5. 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

  6. Health Care Reform:Triple 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

  7. 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

  8. 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

  9. HHSC Proposal to CMS • Dual purpose • Expand existing Medicaid managed care programs, STAR and STAR+PLUS, 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 demonstratedimprovements at the provider level for the receipt of such payments • No mention of expanding coverage

  10. Budget Neutral Proposal June 2011 Projected Texas Medicaid Costs FY 2012-2016 ($Billions)

  11. Budget Neutral?

  12. 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)

  13. DSRIP and UC Pools

  14. 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

  15. 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)

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

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

  18. Milestones & Metrics • Primarily menu driven in Category 1, 2 & 3 • Standardized for Category 4 • Pay for reporting; data from HHSC

  19. Quality Issues • Metrics – appropriateness, baselines • Process or Outcome • Time Horizon

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

  21. Learning Collaboratives • Added requirement by CMS • RHP level and state-wide • Implications for CS&E • Your expertise will be an asset

  22. UT’s 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

  23. UT’s DSRIP Participation There’s no such thing as a free lunch.

  24. 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

  25. Questions? Thank you!

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