Region 15 Regional Healthcare Partnership Orientation Meeting Wednesday, April 25, 2012 University Medical Center of El Paso

Confirmation of Participants

Regional Healthcare Partnership (RHP) Regions

Regional Healthcare Partnership – RHP Region 15 Culberson El Paso Hudspeth Jeff Davis Presidio

Sample Letter

Current HHSC Information

Brief Review Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver Managed care expansion Allows statewide Medicaid managed care services. Includes legislatively mandated pharmacy carve-in and dental managed care. Hospital financing component Preserves upper payment limit (UPL) hospital funding under a new methodology. Creates Regional Healthcare Partnerships (RHPs). Five Year Waiver 2011 – 2016 HHSC received approval from the Centers for Medicare and Medicaid Services (CMS) for the Texas Healthcare Transformation and Quality Improvement Program Waiver on December 12, 2011. The 1115 waiver provides flexibility for Texas to expand risk-based managed care statewide and preserve UPL funding. In Texas approximately $2.8 billion per year are paid to hospitals thru UPL. The state match for the UPL program is provided by counties generally thru local hospital districts. The federal government does not allow UPL to exist in a managed care environment. The Texas proposal to expand Medicaid managed care will save the state $300 million, improved access to care for millions, and dramatically increase the quality of the care delivered. Absent the waiver, the impact to local communities would have been the loss of the $2.8 billion in UPL payments. The waiver protects the UPL funds but redirects those funds in a more accountable and transparent way.

Brief Review Under the waiver, trended historic UPL funds and 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). Unlike UPL, the reimbursement for uncompensated care is limited to costs, not charges. The waiver is funded thru managed care and UPL savings. These savings are achieved directly thru improved utilization management that results from a more efficient delivery model. Local funds, rather than state dollars, will be used as the match to draw down the federal dollars. Over the five-year waiver period approximately $29 billion will be available thru the UC and DSRIP pools.

Impact on Local Entities The waiver provides ways for local entities to access additional federal funding: Through a program and process that is transparent and accountable for public funds. To help pay for health-care services to individuals who are uninsured. To help pay for “incentive” payments (DSRIP) for health-care related projects and investments to increase: Access to health-care services. Quality of health-care and health systems. Cost effectiveness of services and health systems. Regional collaboration and coordination. Unlike UPL, the reimbursement for uncompensated care is limited to costs, not charges. The waiver is funded thru managed care and UPL savings. These savings are achieved directly thru improved utilization management that results from a more efficient delivery model. Local funds, rather than state dollars, will be used as the match to draw down the federal dollars. Over the five-year waiver period approximately $29 billion will be available thru the UC and DSRIP pools.

RHP Principles RHPs are formed around the hospitals currently receiving UPL and one of these would serve as an anchor. Anchors serve as the single point of contact, coordinate RHP activities, and serve administrative functions. The anchor does not make decisions regarding other entities’ funds. Develop plans to address local delivery system concerns with a focus on improved access, quality, cost-effectiveness, and coordination. RHP regions should reflect delivery systems and geographic proximity. UC and DSRIP pools are dependent on RHP plan participation. Waiver funds still go directly to hospitals (not to counties). With an exception for regions without a public hospital. RHP would include all interested IGT-providing entities in a region, and one of these would serve as an anchor. RHP anchors are IGT providers that also serve the following functions for an RHP: Volunteer to serve as the single point of contact for the IGT-providing entities within a RHP Facilitate meetings with interested IGT-contributors in the region towards the development of a RHP plan Ensure public meetings as a part of development of an RHP and prior to submission of a final RHP plan Ensure inclusion of key stakeholders in RHP plan development Coordinate, develop, and provide RHP plan to HHSC based on IGT-contributing entities' projects (consistent with project menus and UC/DSRIP splits required statewide by the waiver). Coordinate required performance reporting for DSRIP to HHSC

RHP Stakeholder Participation RHPs shall provide opportunities for public input in plan development and review. HHSC is seeking broad local plan engagement including: County medical associations/societies. Local government partners. Other key stakeholders. Vision has been that the RHPs develop organically rather than having HHSC impose RHP areas. However, HHSC will provide information and assistance in the development of RHPs.  Will have a list of all IGT contributors that we plan to post on the website Letter going out by mail to about 1,200 hospitals, IGT providers, and related UPL participants to inform them of the waiver changes and ask them if they'd like to participate in webinars.

RHPs and DSRIP RHP Plans include: Regional health assessments. Participating local public entities. 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. Under the waiver, HHSC be able to continue funding needed programs while also investing in transformation projects. An example would be continuing with crisis behavioral health (BH) programs, while using additional funding to support more BH primary and preventive care. over time this should reduce what we would otherwise see in terms of BH crisis needs.

Pool Funding Distribution DY = Demonstration Year

Contact Information Waiver website: http://www.hhsc.state.tx.us/1115-waiver.shtml Waiver email address: TXHealthcareTransformation@hhsc.state.tx.us

Role of the Anchor

Role of the Anchor Anchors serve as RHP Facilitators. Single Point of Contact, Coordinate RHP activities and serve administrative functions. Bring RHP participants and stakeholders together to develop plans for public input and review. Each RHP will have one anchor. Waiver defines anchor as the public hospital. Anchors do not control IGT funding. HHSC to approve anchor by May 1st, 2012.

Community Needs Assessment

Regional Strategic Health Framework Phase 1 – Needs Assessment Report Phase 2 – Priority Ranking Paso del Norte Blue Ribbon Committee

Incorporate Other Needs Assessments Hudspeth County Needs Assessment Presidio County Needs Assessment Jeff Davis County Needs Assessment Culberson County Needs Assessment

Uncompensated Care (UC)

Chapters University Medical Center of El Paso Affiliated Private Hospitals Region 15 County Hospitals Other Entities

DSRIP Menu Outline – HHSC (See Handouts)

I. Infrastructure Development Expand Primary Care Access Expand Specialty Care Access Expand Behavioral Healthcare Access Enhance Health Information Exchange and Health Information Technology for Performance Improvement and Reporting Capacity (meaningful use) Implement and/or Expand Telehealth Implement Disease or Care Management Registry Develop Patient Centered Medical Home Infrastructure Enhance Public Health Preventive Services Improve or Expand Emergency Medical Services

II. Program Innovation and Redesign Reduce Potentially Preventable Admissions/Readmissions (PPA/PPR) Test Financing Mechanisms for Providers Develop Innovations in Health Promotion/Disease Prevention Develop Innovation for Provider Training and Capacity Enhance Behavioral Health Services Innovate in Telehealth Innovate in Supportive Care Reduce Inappropriate Emergency Department Use Improve Patient Experience of Care

III. Quality Improvements Chronic Disease (congestive heart failure, asthma, HIV) Healthcare Acquired Conditions (surgical site infections, MRSA, VRE, pressure ulcers) Perinatal Outcomes Potentially Preventable Admissions/Readmissions Emergency Care (admit decision time to ED departure time for inpatient admissions)

IV. Population-based Improvements At-risk Populations Preventive Health Potentially Preventable Admissions/Readmissions Patient-centered Health Care (patient satisfaction, medication management) Cost Utilization (outpatient imaging) Emergency Department

RHP Document Table of Contents (See Handout)

Table of Contents Page 1 PART ONE: INTRODUCTION 1 Section 1.01 Regional Healthcare Partnership as Association 2 Section 1.02 Purpose of Regional Healthcare Partnership 2 Section 1.03 Mission of Regional Healthcare Partnership 2 Section 1.04 HIPAA Compliance 3 Section 1.05 No Participation of Those Barred From Federal Healthcare Programs 4 PART TWO: GOVERNANCE OF RHP 4 ARTICLE I. ANCHOR 4 Section 1.01 Role of Anchor 4 Section 1.02 Cooperation with Other Governmental Entities 4 ARTICLE II. ORGANIZERS 4 Section 2.01 Qualification and Designation as an Organizer 5 Section 2.02 Termination of Organizer Designation 5 Section 2.03 Role of Organizers 5 Section 2.04 Independent Parties

Table of Contents (con’t.) Page 5 ARTICLE III. REGIONAL PANEL 5 Section 3.01 Number and Powers 6 Section 3.02 Term of Service 6 Section 3.03 Resignation and Replacement 6 Section 3.04 Place of Meetings 6 Section 3.05 Quarterly Meetings 6 Section 3.06 Special Meetings 6 Section 3.07 Quorum 6 Section 3.08 Regional Panel Compensation 6 Section 3.09 Telephonic or Consent Meetings 7 Section 3.10 Eligibility for Uncompensated Care Pool Payments 7 Section 3.11 Eligibility for Delivery System Reform Incentive Payment Pool Payments. 7 Section 3.12 Discretion to Allocate Public Revenue to Uncompensated Care Pool and Delivery System Reform Incentive Payment Pool 8 ARTICLE IV. MEMBERS 8 Section 4.01 Number, Powers and Duties

Table of Contents (con’t.) Page 9 PART THREE: PARTICIPATION IN WAIVER POOLS 9 Overview of UC and DSRIP Pools 9 CHAPTER I. EL PASO COUNTY COMMUNITY NEEDS 9 Section 1.01 El Paso County Needs Generally 12 CHAPTER II. [EXAMPLE: PRESIDIO COUNTY COMMUNITY NEEDS] 12 CHAPTER III. [EXAMPLE: JEFF DAVIS COUNTY COMMUNITY NEEDS] 13 PART FOUR: PARTICIPATION IN UNCOMPENSATED CARE POOL 13 CHAPTER I. CURRENT EFFORTS TO ADDRESS COMMUNITY NEEDS IN EL PASO COUNTY 13 Section 1.01 UC Pool Payments to University Medical Center of El Paso 13 Section 1.02 UC Pool Payments to Private Hospitals Affiliated with District and Participating in this Regional Healthcare Partnership 14 Section 1.03 Efforts to Address Needs of El Paso County During the Waiver. 14 CHAPTER II. [EXAMPLE: CURRENT EFFORTS TO ADDRESS COMMUNITY NEEDS IN HUDSPETH COUNTY] 14 CHAPTER III. [EXAMPLE: CURRENT EFFORTS TO ADDRESS COMMUNITY NEEDS IN JEFF DAVIS COUNTY]

Table of Contents (con’t.) Page 15 PART FIVE: PARTICIPATION IN DELIVERY SYSTEM REFORM INCENTIVE PROGRAM POOL 15 CHAPTER I. EL PASO COUNTY DSRIP POOL 16 Section 1.01 Infrastructure Development Projects for UMC El Paso 20 Section 1.02 Infrastructure Development Projects Available to Private Hospitals 24 Section 1.03 Innovation and Redesign Projects for UMC El Paso 24 Section 1.04 Section Innovation and Redesign Projects Available for Private Hospitals. 27 Section 1.05 Improve Post-Hospitalization Care to Minimize Incidents of Repeat Hospitalizations of Low-Income Residents. 29 Section 1.06 Quality Improvement Projects. 31 Section 1.07 Improvement in Population-Focused Projects. 33 Section 1.08 Allocation of Funding for DSRIP Projects. 33 CHAPTER II. [EXAMPLE: CULBERSON COUNTY DSRIP POOL] 33 Section 2.01 Infrastructure Development Projects for Culberson County.

Table of Contents (con’t.) Page 36 PART SIX: WAIVER POOL FUNDING ALLOCATIONS 36 CHAPTER I. EL PASO COUNTY FUNDING ALLOCATIONS 36 Section 1.01 District Revenue Available for Support of Uncompensated Care Pool and Delivery System Reform Incentive Payment Pool. 36 Section 1.02 District Discretion to Allocate Tax Revenue. 36 CHAPTER II. [EXAMPLE: HUDSPETH COUNTY FUNDING ALLOCATIONS] 36 Section 1.03 County Revenue Available for Support of Uncompensated Care Pool and Delivery System Reform Incentive Payment Pool. 37 Section 1.04 County Discretion to Allocate Tax Revenue. 38 PART Seven: CERTIFICATION38

Medicaid Waiver Timelines

Medicaid Waiver Timeliness July 15 – Submit RHP Chapters to Anchor Sept. 1 – Submit RHP to HHSC Oct. 31- HHSC Submit Final RHP to CMS

Roundtable

Contact Information Waiver website: http://www.hhsc.state.tx.us/1115-waiver.shtml Waiver email address: TXHealthcareTransformation@hhsc.state.tx.us