Texas Healthcare Transformation and Quality Improvement Program Waiver August 20, 2014 Ardas Khalsa Medicaid/CHIP Deputy Director for Healthcare Transformation Waiver

Presentation Outline Delivery System Reform Incentive Payment (DSRIP) Program Current Status Lessons Learned Statewide Learning Collaborative Waiver Renewal

Transformation Waiver Overview Managed care expansion Allows statewide Medicaid managed care services while preserving historical upper payment limit (UPL) funding Supplemental financing component Preserves UPL hospital funding under a new methodology Creates Regional Healthcare Partnerships (RHPs) Five Year Waiver 2011 – 2016

20 RHPs

How Texas DSRIP is Different Intergovernmental transfers (IGT) from governmental entities – largely local public hospital districts – are the non-federal share for DSRIP payments. Approximately 300 DSRIP performing providers – hospitals (public and private), physician groups, community mental health centers, and local health departments. Due to the variety of Texas DSRIP providers, project valuation was less formula-driven than in other states. Almost 1500 DSRIP projects (4-year and 3-year projects) proposed in Category 1 (Infrastructure) or Category 2 (Innovation and Redesign)

DSRIP Status There are 1,491 approved and active DSRIP projects. 1,274 active 4-year projects 217 active 3-year projects Payments to providers were made by July 31, 2014 for metrics approved during April 2014 reporting Providers received approximately $693 million for DY2 and DY3 metrics reported and achieved (for a total of over $2.5 billion paid so far for DY1-3). HHSC received approximately $3.97 million IGT for DSRIP monitoring.

DSRIP Projects – Measuring Success Most DSRIP projects have completed their start-up phase, and have successfully reported achievement of initial project activities. Projects have begun reporting their direct patient impact and establish benchmarks for project outcomes. Providers report twice a year on project metrics and milestones completed to earn DSRIP payments. In the final two years of the waiver, providers will report improvement in outcome measures related to each project. HHSC will conduct a mid-point assessment this year to evaluate the progress of the projects so far, and to determine if they require any modifications or technical assistance to be successful. This assessment will include a review each project’s impact on those served and particularly Medicaid and uninsured individuals, and how the project could be strengthened.

DSRIP Projects – Measuring Success Groups of providers and other DSRIP participants are meeting across the state to work collaboratively to identify best practices, share ways to improve projects, and promote continuous quality improvement. These learning collaboratives are underway in many regions, and a statewide learning collaborative summit for all RHPs will be held September 9-10, 2014. Common topics for the regional learning collaboratives: Behavioral healthcare, including integrated behavioral/primary healthcare Care transitions and patient navigation Chronic care and disease management Reducing unnecessary emergency room use, potentially preventable readmissions Primary care/access HHSC’s formal evaluation of the waiver also will help provide information for the waiver renewal. An interim evaluation report is due to CMS in 2015.

Lessons Learned Texas DSRIP is very different than any other state’s DSRIP program – we are blazing new ground. The waiver has become extremely complex. Volume and variety of projects in Texas Need to automate/streamline as much as possible Timeline pressure up front has resulted in more work later in the process. Reporting - Detailed information needed on each metric, including goal and target, for payment purposes. Valuation review – Need to demonstrate the quantifiable patient impact of each project, including for Medicaid and low-income uninsured individuals.

Lessons Learned CMS Tightening up the structure of DSRIP programs and standardizing them where possible. Because Texas DSRIP is different than other states, certain issues have been a challenge to negotiate. Valuation review Category 3 Emphasis on outcomes Success of individual projects (Category 3) Success of overall RHP efforts (Category 4) DSRIP monitoring and evaluation Learning collaboratives

Statewide Learning Collaborative Summit HHSC is hosting a two day Statewide Learning Collaborative Summit in Austin on September 9 & 10, 2014 at the AT&T Center. The primary goal of the Summit is to share what Texas DSRIP participants have learned from DSRIP so far in order to increase successes as we head into years 4 and 5 of the waiver. We expect to have about 500 people attend in-person, with webinar capability for others. HHSC leadership and CMS representatives will be there.

Statewide Learning Collaborative Summit Guest speakers and DSRIP will present on shared learning and best practices.   Technical assistance also will be included for DSRIP providers, RHP anchors and other stakeholders on topics such setting Category 3 baselines and DSRIP reporting. We expect the Summit will provide valuable information to support waiver extension/renewal efforts.

Statewide Learning Collaborative Summit Shared learning throughout the Summit for DSRIP: What is going well? What changes are occurring as a result of projects? How is success measured in addition to DSRIP metrics? What challenges are providers facing? For example, workforce, data sharing, patient engagement? How are DSRIP projects helping to advance regional systems of healthcare? How are best practices identified and replicated and how do we sustain them?

Waiver Extension/Renewal HHSC must submit a request to the Centers for Medicare & Medicaid Services (CMS) no later than September 30, 2015, to extend the waiver. A waiver extension request must: Meet public notice requirements (30-day public notice and comment period of the extension application and at least two public hearings at least 20 days prior to submitting the application) Include a demonstration summary, demonstration objectives, and provide evidence of how objectives were met.

Waiver Extension/Renewal Elements required in the extension request Historical narrative summary Description of changes requested, if any Enrollment data and projections Description of waivers and expenditure authorities being requested (or that Texas is requesting the same as currently approved) Summaries of External Quality Review Organization and other quality reports Financial data including historical and projected expenditures, and compliance with budget neutrality cap Interim evaluation report for the current demonstration Documentation of compliance with transparency and public notice requirements Documentation of compliance with each of the STCs

Waiver Extension/Renewal A transition plan is due to CMS by March 31, 2015, based on the experience with the DSRIP pools, actual uncompensated care trends in the State, and investment in value based purchasing or other reform options. UC – Texas will need to make a strong case for the continued need for UC in the waiver. How does Texas' UC compare to the amounts available for reimbursement through Medicaid rates, DSH, and UC? Need to examine the interplay between Exchange coverage, Texas' Medicaid coverage, DSRIP and UC. For example, are UC costs increasing due to Exchange Plans (e.g. folks with Exchange Plans lose access to 340b drugs, among other things)? Also, since DSRIP is increasing access to care for Medicaid and low-income uninsured patients, it may increase UC. Be able to tell a story about the impact of UC payments on local communities. Need to determine what data sources are available to demonstrate Texas’ continued UC burden.

Waiver Extension/Renewal DSRIP issues to consider for renewal and the transition plan (continued) Need to show that DSRIP is improving care for individuals, particularly for Medicaid and low-income uninsured patients, as well as population health. Request to continue existing projects that are demonstrating success, but did not get approved and underway until mid-DY2 through mid-DY3? HHSC will continue to work with all of the regions to show measurable improvements in healthcare access and outcomes from DSRIP. Where/how best to gather data to support DSRIP success? Reporting of metrics for payment (project-level metrics for DSRIP Categories 1 and 2) Improvement in outcomes over baseline in 2015-2016 (DSRIP Category 3) Annual hospital-level reporting on potentially preventable events, patient satisfaction, and ED care (DSRIP Category 4). Learning collaborative activities - regional and statewide; rapid, continuous quality improvement activities Mid-point assessment of projects conducted July-November 2014 by Myers and Stauffer, the DSRIP compliance monitoring contractor Formal waiver evaluation by HHSC and Texas A&M

Waiver Extension/Renewal DSRIP issues to consider for the transition plan (continued) A strength of Texas' DSRIP program is its regional approach to delivery system reform, with different types of providers working together to improve care. CMS: System transformation, which is the goal, requires a system approach – not just good projects, but integration of relationships to strengthen systems of care. Texas will need to work to reflect a unified quality strategy for Texas Medicaid managed care and DSRIP. Next Steps HHSC staff will begin to gather information to address all the required elements for extension/renewal Stakeholder survey and stakeholder input meetings

Waiver Communications Find updated materials and outreach details: http://www.hhsc.state.tx.us/1115-waiver.shtml Submit questions to: TXHealthcareTransformation@hhsc.state.tx.us